A nurse is caring for a client who is in labor.

Exhibits

Which of the following actions should the nurse take? Select (3) options.

Rationale:

A. "I need to check food labels for hidden sources of gluten, like barley and rye" is correct and shows appropriate understanding. Clients with celiac disease must avoid gluten-containing grains such as wheat, barley, rye, and their derivatives to prevent intestinal damage and symptoms.

B. "I have to check labels for sugar content" is incorrect and indicates a need for further teaching. Sugar content is not relevant to managing celiac disease. The primary focus should be on identifying and avoiding gluten-containing ingredients, not sugar levels. While a balanced diet is important, checking sugar is not a key part of celiac education.

C. "I can eat any fruits or vegetables that I want to" is correct because all fresh fruits and vegetables are naturally gluten-free, making them safe for someone with celiac disease. This demonstrates accurate understanding of safe food choices.

D. "I need to avoid foods like bread, pasta, and cereal" is correct because these foods typically contain gluten unless labeled gluten-free. Avoidance of gluten-containing products is a fundamental part of celiac disease management.

Rationale:

A. Encourage the client to move to the left lateral position is incorrect because while positioning can help comfort and circulation, it does not correct uterine displacement or a boggy fundus. The primary concern is uterine atony due to bladder distention, not positioning.

B. Encourage the client to perform Kegel exercises is incorrect because Kegel exercises strengthen pelvic floor muscles but do not address uterine atony or displacement. They are appropriate for long-term pelvic floor recovery, not acute fundal management.

C. Assist the client to the bathroom to void is correct because a boggy and displaced fundus often indicates a full bladder, which prevents the uterus from contracting effectively. Urinary retention can lead to uterine atony and postpartum hemorrhage. Having the client void or using a catheter if necessary allows the fundus to return to midline and become firm, reducing bleeding risk.

D. Ask the client to rate her pain is incorrect because while assessing pain is part of routine postpartum care, it does not address the immediate priority of correcting fundal atony and displacement, which can lead to postpartum hemorrhage if left uncorrected.