A multiparous client is admitted to the postpartum unit after a rapid labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged
The nurse has the client void and massages her fundus, but the fundus remains difficult to find and the rubra lochia remains heavy. Which action should the nurse take next?
a. Recheck vital signs.
b. Insert a Foley catheter.
c. Notify the health care provider.
d. Continue to massage the fundus.
ANS: C
Treatment of excessive bleeding requires the collaboration of the health care provider and the nurses. Do not leave the client alone. The nurse should call the clinician while a second nurse rechecks the vital signs. The client has voided successfully, so a Foley catheter is not needed at this time. The uterine muscle can be overstimulated by massage, leading to uterine atony and rebound hemorrhage.
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