A nurse is caring for a client who is 1 hr postpartum. Nurses' Notes 1200: Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion. 1215: Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified. Select the 6 actions the nurse should take.
Explanation & Rationale
A: Correct. Firmly massaging the uterine fundus helps to contract the uterus and reduce bleeding. B: Correct. Providing emotional support helps to calm the client and reduce anxiety, which can worsen bleeding. C: Correct. Administering oxygen helps to improve tissue perfusion and oxygenation, which can be compromised by blood loss. D: Correct. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage. E: Correct. Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively. F: Correct. Administering methylergonovine helps to stimulate uterine contractions and control bleeding. G: Incorrect. Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.