Which priority nursing actions should the nurse perform

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Problem

A nurse is caring for a client who gave birth vaginally and is experiencing heavy vaginal bleeding. Nurse's Notes Vital Signs 5/10 1000 A 28 year-old G3P1 client gave birth vaginally to a 6.7 lbs. (3.04 kgs) newborn after 8 hours of labor. Past medical history of type 2 diabetes mellitus and chronic hypertension 1000 Labor notes indicate this client received epidural for pain management, magnesium sulfate for preeclampsia with severe features, was induced, and the membrane was artificially ruptured. Placenta was expelled after 20 minutes, and non-intact. Provider performed uterine check and manual evacuation of retained placental fragments. Uterine fundus firmed with vigorous massage. Pitocin of 2 units per mL is administered at 150 mL/hr. intravenously. 1030 Bladder distended, uterine fundus boggy, and deviated to the right. The perineal pad is saturated with clots noted, and a pool of blood is noted on the client's backside. Get the instant assignment help. The client reports unable to void after multiple attempts. Primary RN put on call light for help. Which priority nursing action(s) should the nurse perform?

Reference no: EM133870691

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