A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Choice A reason:
Feeling for a full bladder is not the first action the nurse should take, although it is important to assess for bladder distension and urinary retention in postpartum clients. A full bladder can displace the uterus and increase the risk of uterine atony and hemorrhage.

Choice B reason:
Checking the client's fundus is the first action the nurse should take, as it can indicate the tone and position of the uterus. A firm and midline fundus indicates adequate uterine contraction and prevents excessive bleeding. A boggy or deviated fundus indicates uterine atony or retained placental fragments, which can cause hemorrhage.

Choice C reason:
Measuring the client's vital signs is not the first action the nurse should take, although it is important to monitor for signs of shock and infection in postpartum clients. Vital signs can be affected by various factors and do not provide a direct assessment of uterine status.

Choice D reason:
Requesting the provider perform a vaginal examination is not the first action the nurse should take, as it can introduce infection and trauma to the perineum. A vaginal examination is only indicated if there is suspicion of cervical or vaginal lacerations or retained placenta.

Choice A reason: Position the client on her side is correct, as this is the first action the nurse should take according to the ABCDE priority framework. Late decelerations are symmetrical decreases in the fetal heart rate that begin after the peak of the contraction and return to baseline after the contraction ends, which indicate uteroplacental insufficiency and fetal hypoxia. Positioning the client on her side can improve blood flow and oxygen delivery to the placenta and fetus by relieving pressure on the vena cava and aorta.

Choice B reason: Elevate the client's legs is incorrect, as this is not a priority action for a client who has late decelerations. Elevating the legs can increase venous return and cardiac output, but it can also reduce blood flow and oxygen delivery to the placenta and fetus by compressing the vena cava and aorta.

Choice C reason: Administer oxygen via face mask is incorrect, as this is not the first action the nurse should take, although it is important to do later. Administering oxygen can increase oxygen saturation and delivery to the placenta and fetus, but it does not address the cause of uteroplacental insufficiency or improve blood flow.

Choice D reason: Increase the infusion rate of the IV fluid is incorrect, as this is not the first action the nurse should take, although it may be indicated later. Increasing the infusion rate of IV fluid can expand blood volume and improve placental perfusion, but it does not address the cause of uteroplacental insufficiency or improve blood flow. The nurse should obtain a provider's order before increasing the IV fluid rate.