The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery three hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak

Question

The first action of the nurse is to: 1. Assist the client to empty her bladder.
2. Help the client back to bed to check her fundus.
3. Assess her blood pressure and pulse.
4. Begin an IV of lactated Ringer's solution.

Answer 1

2
Rationale:
1. The client might be experiencing a postpartum hemorrhage. Her fundus is not contracting well. Although this might be due to a full bladder, the best first step is to massage the fundus.
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.
3. Massaging the fundus is the top priority because of the excessive blood loss. Blood pressure and pulse do not change until 1,000–2,000 ml of blood has been lost. Massaging the fundus will prevent further blood loss.
4. Massaging the fundus is the top priority because of the excessive blood loss. An IV might need to be started if the client becomes symptomatic.