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5. Perform uterine massage with one hand and the other hand placed above the
simpisis.
R / : Uterine massage stimulate uterine contractions and helps release the
placenta, one hand above simpisis prevent inversion uterine.
2. Note the discoloration of the nail, lip mucosa, gums and tongue, skin
temperature.
R / : With vasoconstriction and relationship to vital organs, circulation in
peripheral tissues is reduced, causing cyanosis and cold skin temperature.
3. collaboration :
Monitor blood gas levels and pH (changes in blood gases and pH levels are a
sign of tissue hypoxia)
Give oxygen therapy (oxygen transport is needed to maximize circulation to
tissue).
Goal : The client can verbalize anxiety and said anxiety is reduced or lost.