A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?
Explanation & Rationale
A. Initiate oxygen therapy by nonrebreather mask: While oxygen may be indicated for hypovolemia or shock, immediate assessment of the cause of hypotension takes priority. Oxygen alone does not address the underlying source of potential postpartum hemorrhage. B. Administer oxytocin infusion: Oxytocin helps contract the uterus and reduce bleeding, but it should be administered after assessing the uterus to confirm atony. Administering medications without assessment could delay targeted intervention. C. Evaluate the firmness of the uterus: Postpartum hypotension can indicate hemorrhage, often caused by uterine atony. Assessing uterine firmness is the priority action because it identifies the source of bleeding and guides rapid interventions to prevent further hemodynamic instability. D. Obtain a type and crossmatch: Preparing for possible transfusion is important in hemorrhage management, but it is not the first action. Immediate assessment and control of bleeding take precedence to stabilize the client.