A nurse is caring for a client having a biophysical profile.
The client asks what the test is for.
What should the nurse include in the response? (Select all that apply.)

Choice A rationale

Increasing fundal massage frequency is not necessary when the fundus is already firm and midline. Fundal massage is primarily used to address uterine atony, which is absent in this scenario. The findings indicate normal post-delivery uterine tone rather than a complication.

Choice B rationale

Documenting the findings and monitoring the client is appropriate when the fundus is firm and midline. The presence of small clots and a large amount of lochia rubra can be normal within the first hour postpartum. Continued observation ensures any potential issues are identified early.

Choice C rationale

Immediate notification of the provider is unnecessary unless there are signs of abnormal bleeding, uterine atony, or other complications. Since the fundus is firm and midline, this suggests the uterine tone is adequate, and intervention is not urgently needed.

Choice D rationale

Encouraging the client to empty her bladder is not relevant here, as the fundus is located appropriately at the midline and umbilical level, indicating that bladder distention is not affecting uterine position. This action would not address the described findings.

Choice A rationale

A positive rubella serum antibody titer indicates immunity to rubella infection, which is protective during pregnancy. It is not an abnormal finding and does not require immediate reporting. Rubella immunity is important to prevent congenital rubella syndrome in the fetus, a severe condition causing defects such as deafness or cardiac anomalies.

Choice B rationale

Blood pressure of 144/94 mmHg is elevated and indicates gestational hypertension, which could progress to preeclampsia if not managed. Preeclampsia can lead to complications such as eclampsia, placental abruption, or maternal and fetal mortality. Normal blood pressure during pregnancy is less than 140/90 mmHg, making this finding critical to report.

Choice C rationale

Copious leukorrhea is a common physiological change in pregnancy due to increased estrogen levels and vascularity. It is usually benign and protective, preventing infections by maintaining a mildly acidic environment in the vagina. This finding does not warrant immediate concern unless associated with infection symptoms.

Choice D rationale

An O-negative blood type requires administration of Rh immunoglobulin to prevent Rh isoimmunization, but this is routinely managed in pregnancy. It is not an urgent issue unless there are concerns about fetomaternal hemorrhage or alloimmunization, which could harm an Rh-positive fetus.