A postpartum client delivered vaginally 2 hours ago and is experiencing heavy bleeding. The nurse assesses the fundus as boggy and displaced to the right. Vital signs are: BP 90/60 mmHg, HR 120 bpm, RR 24/min. What is the nurse's priority action?

Scenario: A client presents with heavy bleeding 2 hours post-vaginal delivery. The fundus is boggy and displaced to the right. Vital signs indicate hypovolemia (BP 90/60, HR 120).

The assessment reveals uterine atony complicated by a distended bladder. The fundal displacement is the critical clue. A full bladder mechanically prevents the uterus from contracting effectively. The priority is to remove this mechanical obstruction using the least invasive method first.

1. First Action: Empty the Bladder
   • Assist the client to void. Provide privacy, run water, or use other measures to stimulate urination.
   • If the client is unable to void within a specified timeframe, perform straight catheterization as ordered to immediately relieve the distention.
2. Second Action: Fundal Massage
   • Once the bladder is empty, immediately reassess the fundus. It should be midline and firm.
   • If the fundus remains boggy, begin fundal massage by cupping one hand above the symphysis pubis and massaging the fundus with the other until it firms.
3. Third Action: Uterotonic Medications
   • If massage is ineffective, initiate or increase the rate of IV oxytocin (Pitocin) as per standing orders. This is the first-line pharmacologic agent.
   • Administer additional uterotonics like methylergonovine (Methergine) only if ordered and after confirming the absence of contraindications such as hypertension.

• Assessment Sequence: Always assess the bladder first when a fundus is displaced from the midline. The sequence is: Bladder, then Massage, then Medication.
• Safety Alert: Never massage a uterus over a full bladder. This is ineffective and can increase the risk of uterine inversion or exacerbate discomfort.
• Ongoing Monitoring: Continuously monitor vital signs, amount of bleeding (weigh pads), and fundal tone. The client’s tachycardia and hypotension require immediate fluid resuscitation and continuous evaluation for shock.