Four hours following an uncomplicated vaginal delivery, a postpartum client reports feeling unusually tired. Upon evaluation, the nurse observes that the client has completely saturated a perineal pad with dark red blood within the last 45 minutes. The current assessment shows a heart rate of 106 beats/minute and a blood pressure of 104/68 mm Hg, a change from the baseline of 82 beats/minute and 126/78 mm Hg. Which action should the nurse take first?
- Massage the uterine fundus and urgently notify the supervising registered nurse.Answer
- BRecord the assessment findings in the electronic health record and reassess in one hour.
- CExplain to the client that this volume of blood loss is a normal part of the recovery process.
- DPlace the client in an upright, seated position to facilitate the drainage of accumulated blood.
Answer
Massage the uterine fundus and urgently notify the supervising registered nurse.
The correct answer addresses the immediate physical need by massaging the fundus to promote uterine contraction while simultaneously escalating the critical situation to the registered nurse. The client's saturated pad and vital sign changes indicate postpartum hemorrhage and early hypovolemic shock, requiring urgent collaborative intervention.
Step-by-Step Solution
Key Concept
Early recognition and escalation of postpartum hemorrhage