What should the nurse do first?  The nurse assesses the vital signs of a client. 4 hours’ postpartum that are as follows: BP 90/60; temperature 100.4?F; pulse 100 weak. thready; R 20 per minute.

Determine the amount of lochia

A weak. thready pulse elevated to 100 BPM may indicate impending hemorrhagic shock. An increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. Thus. the nurse should check the amount of lochia present.Option A: Temperatures up to 100.48F in the first 24 hours after birth are related to the dehydrating effects of labor and are considered normal.Option B: Although rechecking the blood pressure may be a correct choice of action; it is not the first action that should be implemented in light of the other data. The data indicate a potential impending hemorrhage.Option C: Assessing the uterus for firmness and position in relation to the umbilicus and midline is important. but the nurse should check the extent of vaginal bleeding first. Then it would be appropriate to check the uterus. which may be a possible cause of the hemorrhage.