A nurse is planning care for a client in the postpartum unit.
What goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment?

Choice A rationale
The therapeutic effect of IV oxytocin administration following expulsion of the placenta is a firm and midline fundus. Oxytocin stimulates uterine contractions, which helps the uterus return to its pre-pregnancy size and position.
Choice B rationale
Saturating a perineal pad in 1 hr is not a therapeutic effect of oxytocin. This could be a sign of postpartum hemorrhage.
Choice C rationale
A feeling of vaginal fullness is not a therapeutic effect of oxytocin. This could be a sign of a vaginal hematoma.
Choice D rationale
The client’s umbilical cord lengthening is not a therapeutic effect of oxytocin. This could be a sign of placental separation.

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.