Health Promotion and Maintenance
74. A client entered the fourth stage of labor 30 minutes ago. During an assessment, a nurse notes that there is constant trickling of bright red vaginal blood in the presence of a contracted uterus midline at the umbilicus. Which action by the nurse would be most appropriate in this situation?
. Massage the fundus.
. Call the physician.
. Have the client empty her bladder.
. Increase the oxytocin infusion.
Test-Taking Tip
When there is a postpartum hemorrhage, the first consideration is uterine atony. Do not immediately assume that all postpartum bleeding is uterine atony. This client had a contracted uterus, so you must consider other reasons for bleeding that may require a medical, not a nursing, intervention.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications of Diagnostic Tests/Treatments/Procedures
Health Promotion and Maintenance
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Answer 1 is incorrect because fundal massage would be an appropriate intervention for uterine atony. Symptoms of uterine atony would reveal a constant trickle of bright red blood in the presence of a boggy uterus. In this case it is in the presence of a contracted uterus. Answer 2 is correct because a constant trickling of bright red vaginal blood in the presence of a contracted uterus may be an unrepaired laceration of the birth canal. The physician must be notified so that the laceration can be repaired. Answer 3 is incorrect because excessive bleeding caused by a full bladder would reveal a uterus that was above the umbilicus and deviated to the right side. In this case the uterus is midline at the umbilicus. Answer 4 is incorrect because increasing the rate of an infusion of oxytocin would not correct the problem of a lacerated birth canal.