1. What should the nurse do?

Nursing Assessment

 Assess the amount of bleeding.

 Assess maternal vital signs to establish baseline data.
 Assess for signs of shock.
 Assess the condition of the uterus.

Nursing Interventions

 Save all perineal pads used during bleeding and weigh them to determine the
amount of blood loss.
 Place the woman in a side lying position to make sure that no blood is pooling
underneath her.
 Assess lochia frequently to determine if the amount discharged is still within
the normal limits.
 Assess vital signs, especially the blood pressure

2. Independent

Assess vital signs and monitor for signs of shock

Monitor blood loss

 Site

 Type

 Amount- should be no more than 1 perineal pad per hour

 Presence of clots
Monitor and manage pain
Dependent

Administer IV fluids, medications  and blood products as necessary

 Oxytocin

 Antibiotics

 Analgesics