Question

The nurse provides care for a client six hours after a vaginal delivery and assists the client to perform perineal care. Fifteen minutes later, the nurse notes the perineal pad is soaked, and there is blood underneath the client's buttocks. Which action does the nurse take first?

a) Administer pain medication

b) Change the perineal pad

c) Assess the client's vital signs

d) Notify the healthcare provider

Answer 1

The nurse's first action should be to assess the client's vital signs to determine if there's an indication of postpartum hemorrhage, then notify the healthcare provider for further management.

Step-by-step explanation:

If a nurse notices that a client's perineal pad is soaked with blood and there is blood underneath the client's buttocks shortly after a vaginal delivery, the first action the nurse should take is to assess the client's vital signs. This immediate response is essential to determine if the client is experiencing a postpartum hemorrhage, which is a potentially life-threatening condition. After assessing the vital signs for any signs of instability such as hypotension or tachycardia, the nurse should then proceed to notify the healthcare provider about the situation. Postpartum hemorrhage can occur after a vaginal birth and may be due to factors such as uterine atony, retained placenta fragments, or perineal lacerations. It is crucial to act quickly to ensure the safety and well-being of the client.