A nurse is caring for a client who is at 12 weeks of gestation and has hyperemesis gravidarum.

Exhibits

The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?

For each finding click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

Cloudy urine:

Interpretation: Sign of potential improvement

Explanation: Cloudy urine is unrelated to the diagnosis of postpartum hemorrhage. However, it may be a sign of dehydration, and if the client is receiving appropriate interventions, improved hydration may lead to clearer urine.

Fundus at the level of the umbilicus:

Interpretation: Sign of potential worsening condition

Explanation: The fundus at the level of the umbilicus suggests that the uterus is not adequately contracting. This finding is a sign of potential worsening condition as the uterus should be contracting and descending in the postpartum period.

Blood pressure 80/50 mm Hg:

Interpretation: Sign of potential worsening condition

Explanation: A significant drop in blood pressure (80/50 mm Hg) is indicative of hypotension, which can be a sign of worsening postpartum hemorrhage. Hypotension requires immediate attention and intervention.

Moderate lochia rubra:

Interpretation: Unrelated to diagnosis

Explanation: Lochia rubra is the normal vaginal discharge after childbirth and is unrelated to the diagnosis of postpartum hemorrhage. It is a normal part of the postpartum recovery process.

Fundus firm to palpation:

Interpretation: Sign of potential improvement

Explanation: A firm fundus to palpation is a positive sign, indicating that the uterus is contracting and the bleeding may be decreasing. This is a sign of potential improvement.

Thready pulse:

Interpretation: Sign of potential worsening condition

Explanation: A thready pulse is indicative of reduced cardiac output, possibly due to significant blood loss. It is a sign of potential worsening condition and requires prompt intervention.

A. Restrict daily oral fluid intake: Restricting oral fluid intake is not generally recommended unless there is a specific medical indication. Adequate hydration is important, especially postpartum, and fluid restriction may not be appropriate unless there are specific reasons to do so.

B. Administer an IV bolus of lactated Ringer’s: In a client with preeclampsia without severe features, intravenous fluid bolus administration is not the primary intervention. Fluid management is important, but it is typically done judiciously based on the client's specific needs, not as a routine IV bolus.

C. Obtain a prescription for misoprostol: Misoprostol is a medication that is sometimes used to prevent or treat postpartum hemorrhage but is not a routine intervention for a client with preeclampsia without severe features. The focus in preeclampsia management is on blood pressure control and monitoring for signs of worsening disease.

D. Assess for edema: This is the correct action. Assessing for edema is an important component of monitoring a client with preeclampsia. While edema is a common symptom in pregnancy, excessive or sudden-onset edema may be an indication of worsening preeclampsia.