A G2 TPAL 2002 patient experienced a precipitous birth 90 minutes ago. Her infant weighed 4,200 g, and a repair of a second-degree laceration was needed following the birth
The nurse assesses that the patient's uterus is boggy and deviated to the right. The patient's vaginal bleeding has increased. Which action by the nurse takes priority?
A.
Assess the vital signs, including blood pressure and pulse.
B.
Call the health-care provider to examine the woman now.
C.
Massage the uterine fundus with continual lower-segment support.
D.
Measure and document each used perineal pad to assess blood loss.
ANS: C
As the primary caregiver, the registered nurse may be the first person to identify excessive blood loss and to initiate immediate actions. While another member of the team calls the physician or nurse-midwife, the nurse should first locate the uterine fundus and initiate fundal massage.
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