A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours.At 6 hours post-partum, the client is anxious and restless.
On further assessment, a large perineal hematoma is seen.
She is unable to urinate.
After notifying the physician, the nurse should plan to:

Choice A rationale

Placing the patient in a Trendelenburg position is not the immediate priority. This position is often used to manage shock or to improve blood flow to the brain, but it does not directly address the cause of heavy lochia. It may not be the most effective first intervention in this situation.

Choice B rationale

Notifying the physician is important, but the nurse should first attempt to control the bleeding. The physician can be notified after initial measures to stop the bleeding are taken. Immediate intervention by the nurse is crucial in this scenario to stabilize the patient.

Choice C rationale

Administering Methylergonovine can help control postpartum hemorrhage, but this should be done after attempting non-pharmacological measures like fundal massage. Methylergonovine can have side effects and should be used with caution.

Choice D rationale

Massaging the fundus until it is firm is the immediate priority. This can help expel clots and stimulate uterine contraction, which can reduce bleeding. It is a direct and immediate intervention to address the heavy lochia.

Choice A rationale

Respiratory assessment is vital, especially following childbirth, to ensure the mother is not experiencing respiratory issues.

Choice B rationale

Monitoring hemoglobin levels can help identify significant blood loss during delivery, which can lead to anemia and other complications.

Choice C rationale

A heart rate that is elevated postpartum may indicate underlying issues such as infection or hemorrhage, which need to be reported.

Choice D rationale

Continuous blood trickling from the vagina is a warning sign of potential postpartum hemorrhage, which is a medical emergency.