Final answer:
The nurse should immediately assess for signs of postpartum hemorrhage when a client has a firm fundus but is still bleeding profusely after childbirth. Prompt actions include inspection for placental fragments and lacerations, monitoring the characteristics of lochia, and alerting the obstetrician for further evaluation and management.
Step-by-step explanation:
The nurse's first action when caring for a client in the fourth stage of labor who has a firm fundus but is experiencing profuse bleeding should be to assess for possible postpartum hemorrhage. This could include checking the color and amount of bleeding and examining for vaginal and perineal lacerations. It is critical to ensure that no fragments of placenta or fetal membranes remain in the uterus since these could lead to excessive bleeding. The nurse should also confirm if the placenta and membranes have been delivered intact, as retained placental tissue is a common cause of postpartum hemorrhage.
While the firm fundus suggests that the uterus is contracting well, the bleeding could indicate a laceration or other complication that requires immediate attention. The nurse should alert the obstetrician on duty if postpartum hemorrhage is suspected to ensure prompt intervention.
Postpartum care includes observation of lochia, which is the vaginal discharge that occurs after childbirth. It typically transitions from lochia rubra to lochia serosa, and eventually to lochia alba over the course of several weeks. Abnormally heavy or prolonged bleeding could be a sign of complications and warrants further investigation.