A multiparous woman 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 woman void and massages her fundus, but her fundus remains difficult to find, and the rubra lochia remains heavy. The nurse should a. Continue to massage the fundus.
b. Notify the physician.
c. Recheck vital signs.
d. Insert a Foley catheter.
B
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A The uterine muscle can be overstimulated by massage, leading to uterine atony
and rebound hemorrhage.
B Treatment of excessive bleeding requires the collaboration of the physician and
the nurses. Do not leave the patient alone.
C The nurse should call the clinician while a second nurse rechecks the vital signs.
D The woman has voided successfully, so a Foley catheter is not needed at this
time.
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A) Treatment effect B) History threat C) Hawthorne effect D) Selection threat
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a. Attempt to arouse the patient by calling his or her name and lightly shaking the arm. b. Administer oxygen by mask or nasal cannula and notify the prescriber. c. Check the patient's oxygen saturation and raise the head of the bed. d. Document the finding as the only action.