The nurse is assessing a patient who has been diagnosed with an early postpartum hemorrhage. Which findings would the nurse expect? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. A boggy fundus that does not respond to massage
2. Small clots and a moderate amount of lochia rubra on the pad
3. Decreased pulse and increased blood pressure
4. Hematoma formation or bulging/shiny skin in the perineal area
5. Rise in the level of the fundus of the uterus
1,4,5
Rationale 1: A boggy fundus indicates that the uterus is not contracted and will continue to bleed.
Rationale 2: These are normal findings in the postpartal period.
Rationale 3: Increasing pulse and decreasing blood pressure are detected when the patient is bleeding.
Rationale 4: Shiny or bulging skin could indicate the presence of a hematoma.
Rationale 5: The uterine cavity can distend with up to 1000 ml or more of blood, causing the fundus to rise.
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