A nurse is reviewing the assessment findings for a 38-year-old client, RB, under the care of provider

M. Starr MD. The client has a code status of full code and an allergy to Penicillin.

These results indicate that the client is most likely experiencing which condition?

Managing the immediate postpartum period requires applying knowledge of uterine involution and the anatomical relationship between the bladder and uterus. Nurses must recognize how bladder distention affects uterine placement and the subsequent risk of hemorrhage from uterine atony.

Choice A rationale

Notifying the healthcare provider is not the initial step because the clinical findings are characteristic of a full bladder rather than a primary medical emergency. Correcting the bladder distention should occur first to assess if the fundus returns.

Choice B rationale

A full bladder displaces the uterus upward and to the right, preventing effective contraction. Assisting the client to void resolves the displacement, allows the fundus to descend, and promotes uterine contraction, which is the priority to prevent postpartum hemorrhage.

Choice C rationale

Pain medications do not address the physiological cause of a high, deviated fundus. While the client may have discomfort, the priority is mechanical correction of the bladder to ensure uterine safety and prevent excessive bleeding from atony.

Choice D rationale

While a catheter might be needed if the client cannot void, it is more invasive. The nurse should first attempt to assist the client to the bathroom or provide a bedpan before resorting to sterile catheterization.

The nurse must apply knowledge of labor stages and parity. Recognizing that a multiparous client in the transition phase of labor often progresses rapidly to delivery is essential for prioritizing preparation for the second stage of labor and birth.

Choice A rationale

Repositioning every three hours is too infrequent for a client in the transition phase. Furthermore, at 9 cm dilation, the priority is preparing for imminent birth rather than implementing a long-term comfort schedule for early labor.

Choice B rationale

Pushing before the cervix is completely dilated at 10 cm can cause cervical edema or lacerations. The client is currently 9 cm dilated, so instructing her to push now is premature and potentially harmful to the cervix.

Choice C rationale

Initial labor education should occur during the latent phase. By the time a client reaches 9 cm dilation, they are in the transition phase and unable to process complex education due to the intensity of labor.

Choice D rationale

A multiparous client (para 5) at 9 cm dilation is likely to progress to complete dilation and birth very quickly. Preparing delivery supplies immediately ensures that the room is ready for the safe arrival of the newborn..