Question

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action?

1. Record the findings.
2. Massage the fundus.
3. Notify the HCP.
4. Place the client in Trendelenburg's position.

Answer 1

In the given scenario, the initial nursing action should be to notify the HCP.

Step-by-step explanation:

The initial nursing action, in this case, should be to notify the HCP (Healthcare Provider). Excessive bleeding in the fourth stage of labor can be a sign of postpartum hemorrhage, which is a medical emergency. The nurse should inform the HCP promptly to ensure appropriate medical intervention and management.