Question

Select the 6 actions the nurse should take.

a)Provide emotional support.
b)Administer oxygen.
c)Administer terbutaline.
d)Firmly massage the uterine fundus.
e)Weigh the perineal pads.
f)Insert indwelling urinary catheter.
g)Administer methylergonovine.

A nurse is caring for a client who is 1 hr postpartum.

Nurses' Notes
1200:
Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus.
Oxytocin 20 units being administered via continuous IV infusion.

1215:
Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.

Vital Signs
1200:
Temperature 37.5° C (99.5° F)
Heart rate 92/min
Respiratory rate 22/min
Blood pressure 100/60 mm Hg
SaO2​ 97% on room air

1215:
Temperature 37.1° C (98.8° F)
Heart rate 112/min
Respiratory rate 26/min
Blood pressure 90/52 mm Hg
SaO2 92% on room air

Answer 1

Final answer:

The nurse should take the following six actions:

a) Provide emotional support.

b) Administer oxygen.

d) Firmly massage the uterine fundus.

f) Insert indwelling urinary catheter.

g) Administer methylergonovine.

Step-by-step explanation:

The client's vital signs and clinical presentation indicate potential complications postpartum. The elevated heart rate, decreased blood pressure, and cool, clammy skin suggest hypovolemia and inadequate tissue perfusion. The large amount of lochia rubra with clots and a boggy uterine fundus further indicate uterine atony, a common cause of postpartum hemorrhage.

To address hypovolemia, the nurse should administer oxygen (action b) to improve tissue oxygenation and support the client's cardiovascular system. The firm massage of the uterine fundus (action d) helps to stimulate uterine contractions and control bleeding by promoting uterine tone.

The insertion of an indwelling urinary catheter (action f) is essential to monitor urine output and assess fluid balance accurately. This helps in identifying any potential renal complications and ensuring adequate hydration.

Administering methylergonovine (action g) is crucial for managing postpartum hemorrhage caused by uterine atony. Methylergonovine is a uterotonic medication that aids in uterine contraction and control of bleeding.

Providing emotional support (action a) is essential to address the client's anxiety, promoting a sense of reassurance and security during this critical time.

In summary, these actions collectively address the client's physiological and emotional needs, aiming to stabilize vital signs, prevent complications, and ensure the well-being of the postpartum client.