Nursing Interventions Rationale

Persistent, excessive hemorrhage may be life-

Observe onset and amount of blood threatening to the client or may result in
loss; Watch out for signs/symptoms of postpartal infection, postpartal anemia, DIC,
shock. renal failure, or pituitary necrosis attributable to
tissue hypoxia and malnutrition.

Assess for signs of bleeding from Indicates deficiencies or alterations in

gums/mucous membranes or IV site. coagulation.

Reduced kidney perfusion results in reduced

Monitor intake and output. Observe output. When hemorrhage occurs, the anterior
urine specific gravity. pituitary lobe, which enlarges during pregnancy,
is at risk for Sheehan’s syndrome.

Note temperature, WBC count, and Excessive blood loss with decreased Hb
odor and color of vaginal discharge, increases the client’s risk of developing an
obtain culture if appropriate. infection.

Complications such
Provide information about risks of as hepatitis and HIV/AIDS may not be
receiving blood products. manifested during hospitalization, but may
require treatment at a later date.

Monitor for adverse response to

administration of blood products, such Early recognition and intervention may prevent
as allergic or hemolytic reaction; treat a life-threatening situation.
per protocol

Assures correct product will be available if blood

Obtain blood type and crossmatch.
replacement required.

DIC with an associated drop in fibrinogen

levels and a buildup of FSP may occur in
Monitor coagulation studies (e.g.,
response to the release of thromboplastin from
APTT, platelet count, fibrinogen levels,
placental tissue and/or dead fetus. In order for
FSP/FDP).
clot formation to occur, fibrinogen level must be
at least 100 mg/dL.

Maintains circulatory volume to counteract fluid

Administer fluid replacement.
losses/shock

May be indicated to prevent or minimize

Administer antibiotic parenterally.
infection.

Heparin may be used in DIC in cases of fetal

death, or of death of one fetus in a multiple
Administer heparin, if indicated. pregnancy, or to block the clotting cycle by
preserving clotting factors and reducing
hemorrhage until surgical correction occurs.

Administer cryoprecipitate and fresh In clients with DIC, cryoprecipitate replaces

frozen plasma, as indicated. Avoid most clotting factors. Administration of platelets
administration of platelets if during period of continued consumption is
consumption is still occurring (i.e., if controversial, because it may perpetuate the
 clotting cycle, resulting in further reduction of
platelet level is dropping). clotting factors and increasing venous
congestion and stasis.

Treat underlying problem (e.g., surgery

for abruptio placentae or ectopic Stops hemorrhage; reduces likelihood of
pregnancy, bedrest at home for maternal injury.
placenta previa).

See Also
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 Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different
diseases and conditions! Get the complete list!
 Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition,
related factors, goals and nursing interventions with rationale.
Maternal and Newborn Care Plans

Nursing care plans related to the care of the pregnant mother and her infant. See care plans for maternity and obstetric
nursing: