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A nurse is caring for a client who delivered an infant vaginally 2 days ago and notes that there are no clots present in the lochia flow, but there is moderate bleeding with bright red blood and small clots present when massaging the fundus which is firm, midline, and at the level of the umbilicus.
ocument findings as normal is wrong because moderate bleeding with bright red blood and small clots is not normal for lochia flow 2 days after delivery. Lochia is the vaginal discharge that occurs after birth and consists of blood, tissue, mucus and bacteria. Lochia should be dark or bright red for the first 3 to 4 days, but the flow should be light and there should be no clots. Moderate bleeding with bright red blood and small clots indicates that the client may have retained placental fragments or uterine atony.
Massage fundus until it becomes firm is wrong because the fundus is already firm, midline and at the level of the umbilicus, which indicates that the uterus is contracted properly. Massaging the fundus when it is already firm can cause more bleeding and pain.
Administer oxytocin (Pitocin). Oxytocin is a hormone that stimulates uterine contractions and helps reduce postpartum bleeding by closing off the blood vessels that were attached to the placenta.
The nurse should administer oxytocin as ordered by the provider to help the client’s uterus contract and prevent hemorrhage.
Increase IV fluid rate is wrong because increasing IV fluid rate will not stop the bleeding or address the underlying cause. Increasing IV fluid rate may also cause fluid overload or dilutional coagulopathy. The nurse should monitor the client’s vital signs, urine output and hematocrit levels to assess for signs of hypovolemia or anemia due to blood loss.
The correct answer is choice C) Administer oxytocin (Pitocin). Oxytocin is a hormone that stimulates uterine contractions and helps reduce postpartum bleeding by closing off the blood vessels that were attached to the placenta.
The nurse should administer oxytocin as ordered by the provider to help the client’s uterus contract and prevent hemorrhage.
Choice A) Document findings as normal is wrong because moderate bleeding with bright red blood and small clots is not normal for lochia flow 2 days after delivery. Lochia is the vaginal discharge that occurs after birth and consists of blood, tissue, mucus and bacteria. Lochia should be dark or bright red for the first 3 to 4 days, but the flow should be light and there should be no clots. Moderate bleeding with bright red blood and small clots indicates that the client may have retained placental fragments or uterine atony.
Choice B) Massage fundus until it becomes firm is wrong because the fundus is already firm, midline and at the level of the umbilicus, which indicates that the uterus is contracted properly. Massaging the fundus when it is already firm can cause more bleeding and pain.
Choice D) Increase IV fluid rate is wrong because increasing IV fluid rate will not stop the bleeding or address the underlying cause. Increasing IV fluid rate may also cause fluid overload or dilutional coagulopathy. The nurse should monitor the client’s vital signs, urine output and hematocrit levels to assess for signs of hypovolemia or anemia due to blood loss.