Two hours after delivery, a patient's fundus is boggy and has risen to above the umbilicus. The first action the nurse would take is to:
1. Massage the fundus until firm.
2. Express retained clots.
3. Increase the intravenous solution.
4. Call the physician.
1
Rationale 1: Massage of the uterus has to occur before the expression of retained clots.
Rationale 2: Expressing retained clots is not the nurse's first action.
Rationale 3: Increasing the intravenous solution is not a priority in this case.
Rationale 4: The physician does not need to be notified unless either the uterus does not respond to massage or the bleeding does not decrease.
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