Stage 5 — Take action. The PPH response team is at the bedside and concurrent roles have been assigned. Arrange the primary nurse’s assessment–intervention–reassessment loop from first to last.
Ordered Response
Choose your responses, then check the answer.
Explanation
Primary-nurse loop With the team already activated: assess and announce → massage and correct bladder interference → deliver ordered medication and resuscitation → reassess within minutes → escalate if uncontrolled. Other team members perform laboratory, blood-bank, and equipment tasks concurrently.
Step 1 — Define the sequence correctly This is the primary nurse’s local reassessment loop after the hemorrhage team has arrived, not a claim that the entire PPH bundle occurs one task at a time.
Step 2 — Assess, intervene, reassess First establish the current uterine tone, bleeding, QBL, and vital signs and communicate them. Start immediate mechanical measures and relieve bladder interference. Deliver ordered oxytocin, TXA, an appropriate second-line uterotonic, and resuscitation support while assigned teammates perform their tasks.
Step 3 — Escalate from response, not delay Reassess within minutes. Persistent bleeding or instability triggers blood-product/MTP decisions, balloon tamponade, and operative escalation. Notification, blood-bank preparation, and equipment mobilization are already occurring in parallel.
NCLEX rule When an order item represents team care, identify the specific role and closed-loop reassessment sequence instead of serializing the entire emergency response.
Scenario (Stage 5 — Take action)The PPH team is present. Sequence the primary nurse’s immediate bedside loop while other roles proceed concurrently.
Clinical judgment targetUse assess–intervene–reassess–escalate without delaying team activation.
Closed-loop reassessment — A cycle in which the nurse evaluates the response within minutes and escalates when bleeding or instability persists.
Balloon tamponade — An intrauterine device used to apply pressure when uterine bleeding persists despite initial medical and mechanical measures.
Role assignment — Distribution of simultaneous emergency tasks so assessment, medication, resuscitation, laboratory, and escalation work do not wait on one another.