The nurse should take which nursing action when caring for a postpartum client who begins to hemorrhage? (Single best action)

The nurse should take which nursing action when caring for a postpartum client who begins to hemorrhage? (Single best action)

• A. Assess for uterine atony.
• B. Prepare to administer blood or blood products as prescribed.
• C. Insert an indwelling urinary catheter to monitor kidney perfusion.
• D. Administer 8 to 10 L/min of oxygen via non-rebreather face mask.

Answer: (A)

The key idea is recognizing and addressing uterine atony, the most common cause of postpartum hemorrhage, and taking a step that directly targets stopping the bleed. Assessing the uterus to determine its tone guides what to do next. If the fundus is boggy, it indicates atony, and the immediate action is to perform fundal massage to stimulate contraction and to reposition the uterus to a midline, which helps compress blood vessels and reduce bleeding. This assessment-first approach directs subsequent care, such as administering uterotonic medications and initiating IV fluids or blood products as needed. While preparing for blood products, providing oxygen, or catheterizing the bladder are important parts of hemorrhage management, they follow the initial assessment and intervention to restore uterine tone.

The key idea is recognizing and addressing uterine atony, the most common cause of postpartum hemorrhage, and taking a step that directly targets stopping the bleed. Assessing the uterus to determine its tone guides what to do next. If the fundus is boggy, it indicates atony, and the immediate action is to perform fundal massage to stimulate contraction and to reposition the uterus to a midline, which helps compress blood vessels and reduce bleeding. This assessment-first approach directs subsequent care, such as administering uterotonic medications and initiating IV fluids or blood products as needed.

While preparing for blood products, providing oxygen, or catheterizing the bladder are important parts of hemorrhage management, they follow the initial assessment and intervention to restore uterine tone.