Case Study
ATI RN VATI Maternal Newborn Proctored Exam
A nurse is caring for a 28-year-old female client in the labor and delivery unit who is in the fourth stage of labor.A nurse is caring for a 28-year-old female client in the labor and delivery unit who is in the fourth stage of labor. Exhibits Complete the following sentence by using the list of options. The nurse should first monitor the client's dropdown followed by the client's dropdown.
Explanation & Rationale
The nurse should prioritize monitoring the client's fundal tone followed by the client's blood pressure. Here's why: Fundal Tone: The client's fundus is boggy and not firming up with massage. This is a priority concern as it indicates uterine atony, which is a major cause of postpartum hemorrhage. Blood Pressure: Monitoring blood pressure is crucial as the client is experiencing heavy lochia, and a decrease in blood pressure can indicate hypovolemic shock due to blood loss. So, the completed sentence would be: The nurse should first monitor the client's fundal tone followed by the client's blood pressure. Taking care of immediate risks and stabilizing the patient is key in such cases.
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