A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client’s perineal pad. Which of the following actions should the nurse take first?
A.
Request the provider perform a vaginal examination.
B.
Check the client’s fundus.
C.
Measure the client’s vital signs.
D.
Feel for a full bladder.
The Correct Answer and Explanation is:
The correct answer is B. Check the client’s fundus.
Explanation:
After childbirth, lochia rubra, which is the initial postpartum vaginal discharge, is characterized by its red color and consists of blood, tissue, and mucous. The presence of clots can be normal, especially if they are small and the amount of lochia is moderate. However, a large amount of lochia rubra with several clots might indicate potential complications that need to be assessed promptly.
Checking the Fundus:
The fundus is the top of the uterus, and assessing it is crucial for determining whether it is contracting properly. After delivery, the uterus should be contracting to prevent excessive bleeding. If the fundus is found to be boggy (soft and not firm) or displaced from its expected location, it may suggest uterine atony, which is a common cause of postpartum hemorrhage. Proper contraction of the fundus helps in controlling bleeding, and any deviation from this normal process can indicate complications such as postpartum hemorrhage.
Other Actions:
- Request the provider perform a vaginal examination (Option A): While this may eventually be necessary if the bleeding is abnormal or persistent, the immediate priority is to assess the uterus to determine if it is contributing to the problem.
- Measure the client’s vital signs (Option C): Vital signs are important for monitoring the client’s overall condition but are secondary to directly assessing the possible source of bleeding.
- Feel for a full bladder (Option D): A distended bladder can contribute to uterine displacement and bleeding, but the immediate first step should be evaluating the uterine tone and position.
In summary, checking the fundus first is the priority because it directly assesses the most common cause of excessive lochia rubra and clots, which is uterine atony. This assessment helps in determining the next steps for managing and controlling postpartum bleeding.