A nurse is caring for a client who had a vaginal birth 2 hours ago. The client has saturated a perineal pad in 20 minutes. During assessment, the nurse notices that the client has a boggy fundus that is deviated to the right and slightly above the umbilicus. Which intervention should the nurse perform first?

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11ecbb05_cc24_d8ed_b433_4d8c21eaee6c_MD0009_00 Postpartum vaginal bleeding that saturates a perineal padin <1 hour is considered excessive. This client saturated a perineal pad in 20 minutes. Based on the nurse's assessment, the boggy fundus indicates uterine atony. The fundus is also elevated above the umbilicus and deviated to the right, indicating a distended bladder. Bladder distension prevents the uterus from contracting sufficiently to control bleeding at the previous placental site. The client should be assisted to void to correct the bladder distension (Option A). The nurse should then perform fundal massage. (Option B) Oxytocin is a uterotonic that increases contraction of the myometrium, constricting vessels at the previous placental implantation site. An oxytocin infusion should be initiated if initial attempts to control postpartum bleeding (relief of bladder distention and fundal massage) have failed. The usual postpartum oxytocin IV dosage is 125-200 milliunits/min. (Option C) A complete blood count is needed to determine hematocrit and hemoglobin levels following excessive postpartum bleeding. However, this is not the immediate priority. (Option D) Oxygen delivery at 10 L/min via a nonrebreather facemask may be initiated if the client becomes symptomatic following excessive blood loss. However, the first priority is to control the bleeding. Educational objective: Excessive postpartum bleeding is most commonly caused by uterine atony. The nursing priority for uterine atony associated with bladder distension is to assist the client with voiding and then perform fundal massage and other interventions as needed to control excessive bleeding.

A Nurse Is Caring for a Client Who Had a Vaginal