What is your initial nursing intervention


Problem: A patient presents to the postpartum unit 2.5 hours after recovery in labor and delivery. Upon initial assessment the patient's fundus is palpated at the umbilicus but deviated to the right.  Fundal massage assessment is boggy with moderate bleeding and clots.  The patient's vital signs are B/P: 82/50; HR: 112; RR: 14; 02 Sat: 95%.  The patient is complaining of feeling a little lightheaded and the initial void in labor and delivery post-delivery was 10ml.  What is your initial nursing intervention and why?

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