The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3 hours ago. When the patient stands up, blood runs down her legs and pools on the floor. The patient turns pale and feels weak
The first action of the nurse is to: 1. Assist the patient to empty her bladder.
2. Help the patient back to bed to check the fundus.
3. Assess her blood pressure and pulse.
4. Begin an IV of lactated Ringer's solution.
2
Rationale 1: Another action is more important.
Rationale 2: Massaging the fundus is the top priority because of the excessive blood loss. If the fundus is boggy, fundal massage will prevent further blood loss.
Rationale 3: Blood pressure and pulse do not change until 1000–2000 ml of blood has been lost.
Rationale 4: An IV might need to be started if the patient becomes symptomatic.
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