Question

While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?

A) Check vital signs
B) Massage the fundus
C) Offer a bedpan
D) Check for perineal lacerations

Answer 1

The first action a nurse should take when the uterus is boggy with vaginal bleeding post-delivery is to massage the fundus, prompting uterine contractions and reducing bleeding.

Step-by-step explanation:

If a nurse determines that the uterus is boggy and there is vaginal bleeding in the first hour after delivery, the nurse's first action should be to massage the fundus. A boggy uterus indicates that it is not contracting effectively, which can lead to excessive bleeding, or postpartum hemorrhage. Massaging the fundus stimulates uterine contractions to help the uterus contract and to reduce bleeding. After massaging the fundus, the nurse should then check the vital signs to assess the client's overall condition and potential blood loss. Monitoring and acting quickly can be crucial in preventing excessive blood loss and in managing possible postpartum complications.

Continuous postpartum assessment includes observing the lochia and ensuring that no fragments of the placenta remain in the uterus as they can cause postpartum hemorrhage. During this assessment, if other interventions are needed, such as checking for perineal lacerations or offering a bedpan, these should follow the immediate action of massaging the fundus. Detailed documentation of all assessments and interventions is also essential to ensure continuity of care.