If a woman's fundus is soft 30 minutes after birth, the nurse's first response should be to:
a. Take the blood pressure.
b. Massage the fundus.
c. Notify the physician or nurse-midwife.
d. Place the woman in Trendelenburg position.
B
The nurse's first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss.
The blood pressure is an important assessment to determine the extent of blood loss, but it is not the top priority.
Notification should occur after all nursing measures have been attempted with no favorable results.
Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding.
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