A nurse is planning care for a patient who is 12 hours postpartum and has a third-degree perineal laceration. Which of the following interventions should the nurse include in the plan?

Choice A rationale
Preparing the client to receive a plasma expander is not the first action the nurse should take. While it may be necessary in severe cases of hemorrhage, the first action should be to ensure the client’s oxygenation.
Choice B rationale
Administering oxygen via face mask at 10 L/min is the first action the nurse should take. This is because a client who is saturating perineal pads every 10 to 15 minutes is likely experiencing a significant blood loss, which can lead to hypoxia.
Choice C rationale
Inserting an indwelling urinary catheter may be necessary in some cases, but it is not the first action the nurse should take.
Choice D rationale
Collecting hemoglobin and hematocrit levels is important to assess the extent of blood loss, but it is not the first action the nurse should take.

• Fundus 2 cm above umbilicus: This could be a sign of potential worsening condition as it might indicate uterine atony, a condition in which the uterus fails to contract after the delivery, leading to continuous bleeding.
• Blood pressure 90/60 mm Hg: This could be an indication of potential improvement as it is within the normal range, and lower than the previous reading which was elevated due to preeclampsia.
• Heart rate 110/min: This could be a sign of potential worsening condition as it is slightly elevated, which could be a response to blood loss.
• Continued heavy vaginal bleeding: This could be a sign of potential worsening condition as it might indicate postpartum hemorrhage.
• Client reports feeling dizzy: This could be a sign of potential worsening condition as it might be due to blood loss leading to decreased perfusion to the brain.
• Cloudy urine: This is unrelated to the diagnosis. It could be due to dehydration or a urinary tract infection, but it’s not directly related to preeclampsia or postpartum hemorrhage.