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
Feedback
A The blood pressure is an important assessment to determine the extent of blood
loss, but it is not the top priority.
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.
C Notification should occur after all nursing measures have been attempted with no
favorable results.
D Trendelenburg position is contraindicated for this woman at this point. This
position does not allow for appropriate vaginal drainage of lochia. The lochia
remaining in the uterus would clot and produce further bleeding.
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