The nurse is reviewing the client’s chart.

Click to highlight areas of client history and physical that increase the risk for postpartum hemorrhage.

Client was middle aged and married.

She was in labor for 25 hours and forceps were used to assist with the delivery.

She was given an epidural for anesthesia that was effective.

The labor and delivery nurse reported that the client had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale.

Her vital signs were stable, and she was catheterized for 500 mL of light-yellow urine just prior to delivery.

Her spouse was at the bedside for delivery.

Choice A rationale
Preparing the abdominal and perineal areas is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding. This may indicate placenta previa, a condition where the placenta covers the cervical opening, which can cause life-threatening hemorrhage for both the mother and the fetus. The priority is to stabilize the client's hemodynamic status and prevent hypovolemic shock.

Choice B rationale
Initiating IV access is the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding. This allows the nurse to administer fluids and blood products as needed to maintain the client's blood pressure and perfusion. It also provides a route for administering medications such as tocolytics, which can inhibit uterine contractions and reduce bleeding.

Choice C rationale
Inserting a Foley catheter is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding. This may increase the risk of infection and trauma to the lower urinary tract. It is also contraindicated in placenta previa, as it may dislodge the placenta and worsen the bleeding.

Choice D rationale
Administering oxygen via face mask is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding. This may be beneficial to improve the oxygenation of the mother and the fetus, but it does not address the underlying cause of the bleeding or the potential hypovolemia. Oxygen therapy should be initiated after securing IV access and fluid resuscitation.

Choice A rationale
This is incorrect because respirations 16/min are within the normal range and do not indicate magnesium toxicity. The nurse should monitor the client's respiratory rate and report any signs of respiratory depression, such as less than 12/min.

Choice B rationale
This is incorrect because fetal heart rate 158/min is within the normal range and does not indicate fetal distress. The nurse should monitor the fetal heart rate and report any signs of bradycardia, tachycardia, or decreased variability.

Choice C rationale
This is incorrect because headache for 30 min is a common symptom of pre-eclampsia and does not indicate magnesium toxicity. The nurse should administer analgesics as prescribed and report any signs of increased intracranial pressure, such as blurred vision, confusion, or seizures.

Choice D rationale
This is correct because urinary output 40 mL in 2 hr is below the expected amount and indicates renal impairment. The nurse should report this finding to the provider and monitor the client's fluid intake and output, serum creatinine, and blood urea nitrogen levels. The nurse should also assess the client for signs of fluid overload, such as edema, crackles, or dyspnea.