Passage / Scenario

The nurse is caring for a 31-year-old female client.
Item 3 of 5
NursesÔÇÖ Notes
1300: Client is a 31-year-old G2P2 who delivered a healthy female infant (7 lb 14 oz; 3.57 kg) at 39 weeks gestation via spontaneous vaginal delivery. Labor was augmented with oxytocin, and the estimated blood loss at delivery was 400 mL. She was GBS positive and received appropriate antibiotic treatment during labor. Her obstetric history includes anemia during pregnancy and a prior vacuum-assisted delivery complicated by a retained placenta. At approximately one hour postpartum, the fundus is firm and midline at the level of the umbilicus, and lochia is moderate rubra. A second-degree perineal laceration was repaired with 2-0 vicryl. However, the client reports feeling light-headed, appears pale, and her peripad is saturated within 20 minutes.

1315: Client appears diaphoretic and states, ÔÇ£I feel dizzy and something is wrong.ÔÇØ On assessment, fundus is boggy, above the umbilicus, lochia is heavy, with large clots noted.

Orders
1345
ÔÇó Foley catheter