A nurse is caring for a postpartum client who reports heavy vaginal bleeding and passing large clots since delivery 2 days ago.

Which of the following actions should the nurse take first?

The correct answer is choice A, C, D and E. These are the instructions that the nurse should include in the teaching for a client who had a vaginal delivery with a midline episiotomy.

• Choice A is correct because using a sitz bath three times per day and after each bowel movement can help reduce pain, swelling and infection of the perineum.

• Choice C is correct because applying ice packs to the perineum for the first 24 hours can help reduce inflammation and bleeding.

• Choice D is correct because performing Kegel exercises several times per day can help strengthen the pelvic floor muscles and improve urinary continence.

• Choice E is correct because reporting any increase in redness, swelling or discharge from the episiotomy site can help detect signs of infection or wound breakdown.

• Choice B is wrong because wiping from back to front after voiding or having a bowel movement can increase the risk of infection by introducing bacteria from the anal area to the vaginal area.The correct way to wipe is from front to back.

The correct answer is choice C) Administer oxytocin (Pitocin).Oxytocin is a hormone that stimulates uterine contractions and helps reduce postpartum bleeding by closing off the blood vessels that were attached to the placenta.

The nurse should administer oxytocin as ordered by the provider to help the client’s uterus contract and prevent hemorrhage.

Choice A) Document findings as normal is wrong because moderate bleeding with bright red blood and small clots is not normal for lochia flow 2 days after delivery.Lochia is the vaginal discharge that occurs after birth and consists of blood, tissue, mucus and bacteria.Lochia should be dark or bright red for the first 3 to 4 days, but the flow should be light and there should be no clots.Moderate bleeding with bright red blood and small clots indicates that the client may have retained placental fragments or uterine atony.

Choice B) Massage fundus until it becomes firm is wrong because the fundus is already firm, midline and at the level of the umbilicus, which indicates that the uterus is contracted properly.Massaging the fundus when it is already firm can cause more bleeding and pain.

Choice D) Increase IV fluid rate is wrong because increasing IV fluid rate will not stop the bleeding or address the underlying cause.Increasing IV fluid rate may also cause fluid overload or dilutional coagulopathy.The nurse should monitor the client’s vital signs, urine output and hematocrit levels to assess for signs of hypovolemia or anemia due to blood loss.