A nurse is caring for a client who is 1 day postpartum following a cesarean birth. To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client's plan of care?

Choice A reason: Amniotic fluid in the vaginal vault indicates that the membranes have ruptured, but this does not necessarily mean that the client is in labor. Some women may have a slow leak of amniotic fluid for hours or days before labor begins. Rupture of membranes also increases the risk of infection, so the nurse should monitor the client's temperature and fetal heart rate.

Choice B reason: Contractions every 3 to 4 minutes are a sign of labor, but they are not enough to confirm it. The nurse should also assess the duration and intensity of the contractions, as well as the client's response to them. Some women may have false labor contractions, also known as Braxton Hicks contractions, which are irregular, mild, and do not cause cervical changes.

Choice C reason: Pain just above the navel is not a typical sign of labor. It may indicate other problems, such as placental abruption, uterine rupture, or fetal distress. The nurse should report this finding to the nurse midwife and check for other signs of bleeding, shock, or fetal compromise.

Choice D reason: Cervical dilation is the most reliable indicator of labor. It means that the cervix is opening and thinning out to allow the passage of the fetus. The nurse should measure the cervical dilation in centimeters and document it along with the station and effacement of the cervix.

Choice A reason: Massage the client's fundus is correct, as this is the first action the nurse should take according to the ABCDE priority framework. Saturating a perineal pad in 10 min indicates excessive bleeding and possible postpartum hemorrhage, which can compromise the client's airway, breathing, and circulation. Massaging the fundus can stimulate uterine contraction and reduce blood loss.

Choice B reason: Check the client's blood pressure is incorrect, as this is not the first action the nurse should take, although it is important to monitor for signs of shock. Checking the blood pressure does not address the cause of bleeding or prevent further blood loss.

Choice C reason: Administer oxytocin is incorrect, as this is not the first action the nurse should take, although it may be indicated later. Administering oxytocin requires a provider's order and may have adverse effects such as nausea,

vomiting, headache, or water intoxication. The nurse should first atempt to control bleeding by massaging the fundus and then administer oxytocin as ordered.

Choice D reason: Observe for pooling of blood under the butocks is incorrect, as this is not the first action the nurse should take, although it can help estimate blood loss. Observing for pooling of blood does not address the cause of bleeding or prevent further blood loss. The nurse should first atempt to control bleeding by massaging the fundus and then assess for other signs of hemorrhage.