Summary
Summary ( 20 Questions)
A nurse is monitoring a client who had a vaginal birth after cesarean (VBAC) delivery.
The nurse notes that the client has a boggy uterus, heavy vaginal bleeding, and signs of hypovolemic shock.
The nurse suspects that the client has a concealed uterine rupture.
What is an appropriate nursing action for this client?
massaging the fundus and administering methylergonovine can worsen the uterine rupture and increase bleeding. Methylergonovine is a uterotonic drug that can cause uterine contractions and spasm.
inserting an indwelling urinary catheter and measuring urine output is not a priority action for this client. Urine output is an indicator of renal perfusion and fluid status, but it does not address the immediate need of stopping the bleeding and delivering the fetus.
applying ice packs to the perineum and elevating the client’s legs can reduce external bleeding, but not internal bleeding from the uterine rupture.
Ice packs can also cause vasoconstriction
This is because the client has signs of concealed uterine rupture, which is a rare but serious complication of VBAC delivery. Concealed uterine rupture occurs when the uterus tears through the endometrium and myometrium, but the peritoneum remains intact. This can cause heavy vaginal bleeding, hypovolemic shock, and fetal distress. The priority nursing action is to restore the client’s blood volume and prepare for emergency surgery to deliver the fetus and repair the uterus.
This is because the client has signs of concealed uterine rupture, which is a rare but serious complication of VBAC delivery. Concealed uterine rupture occurs when the uterus tears through the endometrium and myometrium, but the peritoneum remains intact. This can cause heavy vaginal bleeding, hypovolemic shock, and fetal distress. The priority nursing action is to restore the client’s blood volume and prepare for emergency surgery to deliver the fetus and repair the uterus.