Clara Guidry Scenario 1
You enter the patient's room. After washing and gloving hands, you introduce yourself and verify identities of the patient, Mrs. Clara Guidry and the baby. Assessment findings: Blood pooling under buttocks with several large clots; fundus boggy and slightly deviated to the right, 3 cm. above umbilicus; Vital signs: BP 90/60, P 110, R. 20, SAO2 98%, skin color pale, patient alert and oriented; unable to move legs, holding and breastfeeding baby. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:
1Assist mother to unlatch infant from breast and place infant in crib or hand to the husband.Patient is light-headed and hypovolemic putting infant at risk of falling from mother's arms. Infant safety is a first priority.
2Massage uterine fundus.Massaging the fundus until firm and tightly contracted closes off blood vessels at the placental site and stops bleeding.
3Call for help using emergency call system.Postpartum hemorrhage is the leading cause of morbidity and mortality requiring a rapid, team approach to patient management.
4Set oxytocin rate to Bolus on IV pump as ordered by healthcare provider.Rapid infusion of oxytocin causes a sustained contracted uterus, thereby clamping off blood vessels from placental site and preventing hemorrhage.
5Assess bladder status and need to perform straight catheter.A full bladder displaces the uterus and contributes to hypotonia and uterine atony. Her uterus is slightly deviated to the right, indicating a potential need for catheterization.