Question

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated in blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action?

1. Call the health care provider.
2. Assess the client's vital signs.
3. Gently message the uterine fundus.
4. Administer a 300-mL bolus of a 20 units/L oxytocin (Pitocin) solution.

Answer 1

The nurse should first massage the uterine fundus to help prevent postpartum haemorrhage by encouraging the uterus to contract. If bleeding persists, other interventions would follow, such as administering oxytocin and calling for medical support.

Step-by-step explanation:

The nurse's initial action upon finding the client's perineal pad saturated in blood and blood soaked into the bed linen under the client's buttocks should be to gently massage the uterine fundus. This is because the fourth stage of labour involves the recovery period post-delivery of the baby and placenta, where the uterus should contract to stop the bleeding from the placental site. If the fundus is not firm upon palpation (which can suggest uterine atony), massage can help the uterus contract, which is crucial to prevent further excessive bleeding, a condition known as postpartum haemorrhage (PPH). If the bleeding does not subside, the nurse should then perform other interventions like assessing the client's vital signs, administering a bolus of oxytocin, and calling the health care provider for further management.

It The obstetrician must examinee expelled placenta and fetal membranes to ensure that they are intact. Retained placental fragments can cause postpartum haemorrhage. Continued uterine contractions are critical for involution and to prevent excessive postpartum bleeding.