A licensed practical nurse is collecting data from a client who is 12 hours postpartum following an uncomplicated vaginal delivery. The nurse observes that the client has completely saturated a perineal pad with lochia rubra over the past 45 minutes. Upon palpation, the uterine fundus is boggy and located 2 centimeters above the umbilicus. Which action should the nurse take first?
- Gently massage the client's uterine fundus until it becomes firm.Answer
- BAdminister a prescribed intravenous dose of a uterotonic medication.
- CDocument the bleeding volume and fundal position as expected findings.
- DNotify the registered nurse immediately to prepare for a laceration repair.
Answer
The correct action is to gently massage the client's uterine fundus until it becomes firm.
In the presence of a boggy (soft) uterus and heavy vaginal bleeding, the priority nursing action is to firmly but gently massage the fundus. This mechanical stimulation promotes immediate uterine contraction, which compresses the blood vessels at the placental site and controls postpartum hemorrhage caused by uterine atony. This is a primary, life-saving intervention that falls well within the practical nurse's scope of practice.
Step-by-Step Solution
Key Concept
Postpartum Hemorrhage and Uterine Atony