A nurse is caring for a group of clients on a postpartum unit.
Which of the following findings should be reported to the RN immediately?

Rationale for Choice A:

Having the client pant during the next few contractions is not appropriate at this time. While panting can be a helpful

breathing technique during earlier stages of labor, it is not recommended when the client feels the urge to push.

Panting can actually delay the progress of labor by preventing the client from bearing down effectively.

It is important to allow the client to push when she feels the urge, as this will help to facilitate the descent of the fetal head and

progress labor.

Rationale for Choice B:

Helping the client to the bathroom to empty her bladder is not the priority action at this time. While a full bladder can

sometimes interfere with labor progress, it is more important to assess the perineum for signs of crowning before taking the

client to the bathroom.

If the fetal head is crowning, it is crucial to avoid any unnecessary delays in delivery.

Rationale for Choice C:

Assisting the client into a comfortable position is important for labor progress, but it is not the priority action at this time.

Assessment of the perineum for signs of crowning takes precedence, as it will guide the nurse's subsequent actions.

Once crowning is confirmed, the nurse can then help the client into a position that facilitates pushing, such as squatting, semi-

sitting, or side-lying.

Rationale for Choice D:

Assessing the perineum for signs of crowning is the most appropriate action for the nurse to take in this situation.

Crowning is the term used to describe the appearance of the fetal head at the vaginal opening.

It is a definitive sign that the client is in the second stage of labor and that delivery is imminent.

By assessing for crowning, the nurse can confirm the progress of labor and prepare for the delivery of the baby.

Choice A rationale:

Increasing fluid intake is not the priority action in this situation. While maintaining adequate hydration is important for

postpartum recovery, it does not directly address the immediate concern of excessive bleeding. Excessive fluid intake could

potentially worsen the bleeding by increasing blood volume and potentially increasing blood pressure.

Choice C rationale:

Helping the client use the bedpan to urinate is not the priority action in this case. While a full bladder can sometimes interfere

with uterine contraction and contribute to postpartum bleeding, it is not the most likely cause of the excessive bleeding in this

scenario. The client has already saturated two perineal pads in a short period, indicating a more significant bleeding issue that

needs to be addressed first.

Choice D rationale:

Preparing to administer tocolytic medication is not the appropriate action at this time. Tocolytic medications are used to stop

contractions, but they are not typically used to manage postpartum hemorrhage. In fact, tocolytics could potentially worsen

the bleeding by interfering with the natural mechanisms that help the uterus contract and stop bleeding after delivery.

Choice B rationale:

Checking the consistency of the client's uterine fundus is the priority action in this situation. The most common cause of

postpartum hemorrhage is uterine atony, which means the uterus is not contracting effectively to clamp down on the blood

vessels where the placenta was attached. A soft, boggy fundus is a sign of uterine atony. By assessing the fundus, the nurse can

quickly determine if uterine atony is the likely cause of the bleeding and take appropriate interventions to manage it.