Nokea
The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, he preceding nurse indicated that the patient’s lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient’s peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse’s priority action with this finding?
Correct Answer: C
Rationale: The correct answer is C: Contact the health care provider. This is the priority action because the sudden increase in lochia flow after breastfeeding could indicate postpartum hemorrhage, which is a serious complication that requires immediate medical attention. Contacting the healthcare provider will allow for prompt assessment and intervention.
A: Weigh the peripad - This is not the priority action as assessing the amount of blood loss is important, but contacting the healthcare provider for further assessment and intervention takes precedence.
B: Replace the peripad - While maintaining cleanliness and hygiene is important, addressing the potential postpartum hemorrhage is the priority.
D: Document the finding in the patient’s chart - Documentation is necessary but should come after the immediate concern of postpartum hemorrhage is addressed.