A nurse is caring for a client who is postpartum and received a bolus of Oxytocin 30 units in 500 mL of NS over 1 hour following delivery of the placenta.
Which of the following findings indicates that the medication was effective?

Choice A rationale

The client is exhibiting expected assessment findings. Three days postpartum, it is normal for the fundus to be three fingerbreadths below the umbilicus, lochia rubra to be light, and the breasts to be full and warm to palpation without evidence of redness or pain. These findings indicate that the uterus is involuting properly, and the breasts are producing milk for breastfeeding.

Choice B rationale

The client is not exhibiting indications of mastitis. Mastitis is characterized by breast tenderness, redness, warmth, and pain, often accompanied by fever and flu-like symptoms. The absence of these symptoms suggests that the client does not have mastitis.

Choice C rationale

There is no indication that the client should be advised to remove her nursing bra. A well-fitting nursing bra can provide support and comfort during breastfeeding. The client should continue to wear a nursing bra as needed.

Choice D rationale

There is no indication that the client should be advised to stop breastfeeding. The assessment findings suggest that breastfeeding is going well, and the client should be encouraged to continue breastfeeding to provide optimal nutrition for the infant.

Choice A rationale

Asking the client to rate her pain is important for assessing discomfort, but it does not address the immediate issue of a deviated fundus. A deviated fundus often indicates a full bladder, which can impede uterine contraction and increase the risk of postpartum hemorrhage.

Choice B rationale

Encouraging the client to perform Kegel exercises is beneficial for pelvic floor strengthening but does not address the immediate concern of a deviated fundus. The priority is to ensure the uterus can contract properly.

Choice C rationale

Assisting the client to the bathroom to void is the correct action. A full bladder can displace the uterus, preventing it from contracting effectively and increasing the risk of hemorrhage. Voiding helps the uterus return to its proper position and function.

Choice D rationale

Encouraging the client to move to the left lateral position may provide comfort but does not address the underlying issue of a full bladder causing uterine displacement.