A nurse is caring for a new mother during the fourth stage of labor and assesses the following: patient has soaked two peri-pads in 45 minutes, pulse is 118 beats/minute, and blood pressure is 90/62 mm Hg. Which action by the nurse is most important?
A.
Assess the firmness of the patient's uterus.
B.
Document the findings and reassess in 15 minutes.
C.
Encourage the woman to attempt breastfeeding.
D.
Escort the woman to the bathroom to void.
ANS: A
Hypotension, tachycardia, excessive bleeding (more than one peri-pad in the first hour), and a boggy, noncontracting uterus are all danger signs of postpartum hemorrhage. Based on this woman's signs and symptoms, the nurse should assess her uterus and, if necessary, begin uterine massage. Documentation needs to be thorough, but further action is needed. Breastfeeding does stimulate the uterus, but this action is not the priority in a possible emergent situation. A hypotensive woman should not be ambulated.
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