A 37-year-old gravid 8 para 7 woman was admitted to the postpartum unit at 2 hours postbirth. On admission to the unit, her fundus was U/U, midline, and firm, and her lochia was moderate rubra
An hour later, her fundus is midline and boggy, and the lochia is heavy with small clots. Based on this assessment data, the first nursing action is:
a. Massage the fundus of the uterus.
b. Assist the woman to the bathroom and reassess the fundus.
c. Notify the physician or midwife.
d. Start IV oxytocin therapy as per standing orders.
ANS: a
Feedback
a. Correct. Based on the assessment data that the uterus is midline and boggy, the woman is experiencing uterine atony.
b. Assisting the woman to the bathroom would be a nursing action if the uterus was not midline.
c. Oxytocin would be given and the primary health provider would be notified if the uterus did not respond to uterine massage.
d. Oxytocin would be given and the primary health provider would be notified if the uterus did not respond to uterine massage.
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