A nurse is caring for a postpartum client who just delivered a newborn weighing 4.5 kg (10 lb). Which of the following signs should the nurse recognize as a potential indication of hemorrhage?

• Urine pH 5.0: This is an improvement as the pH has increased from 4.4, moving closer to the normal range (4.6 to 8).
• Urine specific gravity 1.050: This is a sign of potential worsening as the specific gravity has increased from 1.040, indicating possible dehydration.
• 3+ ketones: This is a sign of potential worsening as the presence of ketones has increased from 2+, indicating the body is breaking down fat for energy due to insufficient glucose.
• Urinary output 40 mL/hr: This is an improvement as the urinary output has increased from 20 mL/hr, indicating better hydration.
• Heart rate 130/min: This is a sign of potential worsening as the heart rate has increased from 128/min, possibly due to dehydration.
• WBC count 10,000/mmt: This is unrelated to the diagnosis as it’s within the normal range (5,000 to 10,000/mm³) and doesn’t directly relate to the client’s symptoms of vomiting and dehydration.

Choice A rationale
Performing a fundal massage is not the appropriate action for a client with placenta previa who is experiencing a large amount of vaginal bleeding. Fundal massage is typically used to stimulate contractions and reduce postpartum hemorrhage after the delivery of the placenta. However, in the case of placenta previa, where the placenta is covering the cervix, a fundal massage could potentially cause more harm and increase bleeding.
Choice B rationale
Assessing for abdominal tenderness is not the most immediate action for a nurse to take when a client with placenta previa is exhibiting a large amount of vaginal bleeding. While abdominal tenderness could indicate a complication such as placental abruption, the primary concern with placenta previa is the risk of severe bleeding that can endanger both the mother and the baby.
Choice C rationale
Obtaining serial hemoglobin and hematocrit is the correct action in this situation. These laboratory tests are important for monitoring the client’s blood loss and determining the need for a possible blood transfusion. With a large amount of vaginal bleeding, the client is at risk for anemia and hypovolemic shock, so close monitoring of blood levels is crucial.

Choice C rationale

Monitoring vital signs closely is an important part of care for any client, but it is not the most specific action a nurse should take for a client with placenta previa who is experiencing a large amount of vaginal bleeding. Vital sign changes could indicate worsening of the client’s condition, but these changes often occur late in the progression of blood loss. Therefore, while important, it is not the most immediate action to take.