Maternal / Newborn Question #27

Question

The nurse is caring for a woman who is in the recovery (4th stage of delivery) following normal vaginal delivery. The client is bleeding despite the fundal massage. Which intervention by the nurse has priority to decrease the bleeding?

Answers

  1. Assist the client to empty the bladder.
    • Rationale:
  2. Increase the Pitocin drip rate.
    • Rationale:
  3. Document the occurrence and continue to monitor.
    • Rationale:
  4. Massage the fundus again.
    • Rationale:

Overview

Explanation

The correct answer is A. A full bladder will impede the contracting force of the uterus which will increase the risk of bleeding. Increasing the Pitocin drip or rate will not help the uterus if the bladder is the primary problem. This is a problem that should not only be monitored, and massaging the fundus will not take care of the real problem—full bladder.

Learning Outcomes

Test Taking Tip

Video Rationale