A 28-year-old primigravida delivered a 3,800-gram infant vaginally 2 hours ago after a prolonged labor and is experiencing heavy bleeding. Which nursing action should be the FIRST priority?

In a patient presenting with heavy bleeding two hours after a vaginal delivery, the clinical presentation is highly suggestive of postpartum hemorrhage (PPH). PPH remains a major obstetric emergency and a leading contributor to maternal morbidity and mortality, making early recognition and systematic evaluation critical for effective management ^[1]. The immediate priority is not to initiate a treatment blindly, but to perform a rapid, focused assessment to identify the most likely cause of the hemorrhage so that the subsequent intervention is targeted and effective.

The most common cause of PPH in the immediate postpartum period is uterine atony, a condition where the uterus fails to contract adequately after placental separation. Risk factors present in this scenario, such as a prolonged labor and the delivery of a macrosomic infant (3,800 grams), significantly increase the likelihood of an over-distended, fatigued uterus that cannot maintain hemostatic contraction. A structured clinical approach dictates that the first step is to confirm this diagnosis and provide a mechanical intervention to stimulate uterine contraction ^[1]. Therefore, assessing the fundus to determine if it is boggy, displaced, and above the umbilicus, followed immediately by fundal massage, is the foundational priority action. This assessment and initial mechanical intervention can often control bleeding at its source and prevent progression to severe hypovolemia.

The other options represent critical subsequent steps in the management of PPH, but they are not the first priority. Administering a prescribed oxytocin infusion (Option 1) is a first-line pharmacologic therapy for uterine atony, but it should be initiated after or concurrently with fundal massage, once the atonic uterus is confirmed. Inserting a large-bore IV catheter (Option 2) and preparing for an emergency blood transfusion (Option 4) are essential components of managing hypovolemic shock from hemorrhage. However, these are resuscitative measures that address the consequence of the bleeding rather than the primary cause. The systematic evaluation of the "Four T's" (Tone, Trauma, Tissue, Thrombin) begins with assessing Tone, making fundal assessment and massage the correct initial nursing action to directly address the underlying etiology and prevent further blood loss ^[1].