A nurse is performing a 1-hour postpartum assessment on a client who had a spontaneous vaginal delivery. The nurse notes heavy vaginal bleeding, and the uterine fundus is palpated as soft, boggy, and displaced to the right of the umbilicus. Arrange the following nursing actions in the correct priority sequence from first to last.
- 1Massage the uterine fundus until it becomes firm.
- 2Assist the client to empty her bladder.
- 3Administer a prescribed as-needed uterotonic medication.
- 4Notify the healthcare provider of the client's status.
- 5Document the assessment findings and interventions.
Answer
The correct priority sequence is to first massage the uterine fundus, then assist the client to empty her bladder, administer a prescribed uterotonic medication, notify the healthcare provider, and finally document the findings.
In the setting of a boggy and deviated fundus, the nurse must prioritize immediate physiological stabilization. The first action is always to perform fundal massage to stimulate contraction and slow active hemorrhage. Next, the underlying cause of the deviation (a distended bladder) must be addressed by assisting the client to void or catheterizing. If these non-pharmacological measures are insufficient, administering a prescribed uterotonic is the next logical step to ensure sustained contraction. Escalation to the healthcare provider follows if the client remains unstable, and documentation is completed once the clinical emergency is managed.
Step-by-Step Solution
Key Concept
Management of Postpartum Hemorrhage and Uterine Atony