A nurse is caring for a postmenopausal client prescribed the aromatase inhibitor, anastrozole, for the treatment of breast cancer. Which of the following should the nurse tell the client she may experience?

Choice A rationale:

Assisting the client to void is a priority intervention in this situation. A full bladder can displace the uterus and prevent it from contracting effectively, leading to a boggy and high- positioned fundus. After the client empties her bladder, the nurse should reassess the fundus to ensure it has descended to its appropriate location, which is usually at or just below the level of the umbilicus.

Choice B rationale:

Documenting the findings as within normal limits is incorrect because a firm, displaced fundus that is 3 cm above the umbilicus is not considered normal. This finding indicates that the uterus is not contracting adequately, and the nurse should take appropriate actions to address the issue.

Choice C rationale:

Gently massaging the client's fundus is not the correct intervention in this case. Massaging a firm fundus could cause uterine irritation and should be avoided. Instead, the nurse should encourage the client to empty her bladder, which often helps the uterus contract and descend to its proper position.

Choice D rationale:

Encouraging the client to ambulate may be helpful in some cases to promote uterine contractions and involution. However, in this situation, the priority is to address the full bladder, as it is a common cause of a displaced and high fundus shortly after delivery.

The correct answers are C, D, E.

Choice A reason:

Performing a vaginal exam is contraindicated in placenta previa because it can disrupt the placenta and cause significant bleeding.

Choice B reason:

Monitoring fetal heart rate with an internal fetal monitor is not recommended as it involves a vaginal exam, which poses a risk of bleeding in placenta previa cases.

Choice C reason:

Frequently assessing maternal heart rate is important to detect any changes that could indicate maternal hemorrhage or other complications.

Choice D reason:

Initiating bed rest with bathroom privileges is advised to minimize the risk of bleeding and to ensure the safety of both the mother and the fetus.

Choice E reason:

Having oxygen equipment available is essential to manage potential fetal distress, which can occur with placenta previa.