The nurse is assisting a multiparous postpartum woman to the bathroom for the first time since her delivery 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. Which is the priority nursing action?
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 infusion.
2
Explanation:
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 priority nursing action is to assess and massage the fundus.
2. Massaging the fundus is the priority because of the excessive blood loss. If the fundus is boggy, fundal massage may stimulate toning of the uterus and 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 1000 to 2000 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.
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