A 25 year-old woman gave birth to her second child 6 hours ago. She informs the nurse that she is bleeding more than with her previous birth experience. The initial nursing action is to:
a. Explain that this is normal for second-time moms.
b. Assess the location and firmness of the fundus.
c. Change her pad and return in 1 hour and reassess.
d. Give her 10 units of oxytocin as per standing order.
ANS: b
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a. The nurse should not inform the patient that this is normal until she has assessed for the degree and potential cause of bleeding.
b. It is important to first assess for uterine atony or displaced uterus from full bladder.
c. If the uterus is firm and midline, then the nurse should change the pad and return within 30 minutes to assess the amount of lochia.
d. The nurse would give oxytocin if the uterus is boggy and does not respond to uterine massage.
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