A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7-pound infant four hours ago by cesarean delivery. Which nursing problem has the highest priority?

A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7-pound infant four hours ago by cesarean delivery. Which nursing problem has the highest priority?

• A. Impaired parenting related to inexperience.
• B. Acute pain related to abdominal incision.
• C. Risk for injury related to uterine atony.
• D. Ineffective breastfeeding related to fatigue.

Answer: (C)

The key idea is preventing postpartum hemorrhage from uterine atony in a patient who just delivered and is receiving magnesium sulfate. Magnesium sulfate, used for preeclampsia, relaxes smooth muscle, including the uterus. After delivery, a uterus that doesn’t contract firmly fails to compress the blood vessels at the placental site, leading to heavy vaginal bleeding and potential hemorrhagic shock. Because this patient delivered via cesarean only four hours ago, the risk of significant blood loss is immediate and life-threatening, making risk for injury due to uterine atony the highest-priority nursing problem. Addressing this priority involves maintaining uterine tone and stability: assess the fundus for firmness and midline position, perform fundal massage if the uterus feels boggy, and ensure uterotonic medications are given as prescribed to promote contraction. Monitor lochia for changes in amount or clots, watch vital signs for signs of hemorrhage (rapid pulse, low blood pressure), and keep the bladder from distending, which can impede uterine contraction. Be prepared to escalate care quickly if bleeding increases, including notifying the team and having blood products or surgical options available if needed. While pain management and breastfeeding support are important, they are secondary to preventing hemorrhage in this immediate postpartum period.

The key idea is preventing postpartum hemorrhage from uterine atony in a patient who just delivered and is receiving magnesium sulfate. Magnesium sulfate, used for preeclampsia, relaxes smooth muscle, including the uterus. After delivery, a uterus that doesn’t contract firmly fails to compress the blood vessels at the placental site, leading to heavy vaginal bleeding and potential hemorrhagic shock. Because this patient delivered via cesarean only four hours ago, the risk of significant blood loss is immediate and life-threatening, making risk for injury due to uterine atony the highest-priority nursing problem.

Addressing this priority involves maintaining uterine tone and stability: assess the fundus for firmness and midline position, perform fundal massage if the uterus feels boggy, and ensure uterotonic medications are given as prescribed to promote contraction. Monitor lochia for changes in amount or clots, watch vital signs for signs of hemorrhage (rapid pulse, low blood pressure), and keep the bladder from distending, which can impede uterine contraction. Be prepared to escalate care quickly if bleeding increases, including notifying the team and having blood products or surgical options available if needed. While pain management and breastfeeding support are important, they are secondary to preventing hemorrhage in this immediate postpartum period.