A primigravida arrives at the maternity unit’s observation area because she believes she is in labor.
The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats per minute and contractions are occurring irregularly every 10 to 15 minutes.
Which assessment finding would confirm to the nurse that the client is not in labor at this time?

Choice A rationale

While notifying the healthcare provider of the assessment findings is important, it would not be the first action to take. The nurse should first gather more information about the client’s condition.

Choice B rationale

Obtaining a STAT hemoglobin and hematocrit would not be the first action to take. These tests could provide information about the client’s blood volume and potential for anemia, but they would not directly address the client’s complaint of a severe headache.

Choice C rationale

Determining if the client received anesthesia during delivery is the correct first action. A severe headache in the postpartum period can be a sign of a post-dural puncture headache, which can occur as a complication of spinal or epidural anesthesia.

Choice D rationale

Assigning a practical nurse (PN) to reassess the client’s vital signs would not be the first action to take. While ongoing monitoring of the client’s vital signs is important, the nurse should first investigate the potential cause of the client’s severe headache.

Choice A rationale

While hard, painful uterine afterpains can be uncomfortable for the patient, they are a normal part of the postpartum period and are not typically a priority complication following a severe postpartum hemorrhage16.

Choice B rationale

Disseminated intravascular coagulation (DIC) is a serious condition that can occur as a complication of severe postpartum hemorrhage. It involves an overactive clotting process leading to the formation of small blood clots that can block blood vessels and cause significant organ damage16.

Choice C rationale

Postpartum psychosis is a serious mental health disorder that can occur after childbirth. However, it is not directly related to postpartum hemorrhage and would not typically be the priority complication in this scenario16.

Choice D rationale

Placenta accreta is a condition where the placenta grows too deeply into the uterine wall. While it can cause severe bleeding after delivery, it would not typically be a priority complication to assess for following a severe postpartum hemorrhage16.