After assisting the provider with an amniotomy on a laboring client, what is the nurse's priority action?

Choice A rationale

A localized area of breast tenderness is a potential sign of mastitis, which, while requiring attention, is not an immediate life-threatening condition. The client can be seen after more acute priorities, as mastitis typically develops over days.

Choice B rationale

A pain score of 3/10 in a 4-hour post-op client is an expected finding and can be addressed after more critical clients. This level of pain is not indicative of an acute, unstable physiological state that requires immediate intervention.

Choice C rationale

Moderate, dark red lochia is a normal finding 4 hours postpartum. The lochia is a mixture of blood, tissue, and mucus, and its color and amount are expected to change over time without indicating an immediate danger to the client.

Choice D rationale

Uterine tenderness, foul-smelling lochia, and a new temperature of 102 degrees F are classic signs of postpartum endometritis, a serious uterine infection. This presents a high risk for sepsis and septic shock, making it the highest priority for immediate assessment and intervention. .

Choice A rationale

Massaging a fundus that is already firm is not necessary and could be uncomfortable for the client. The primary issue in this scenario is the deviated position of the fundus, which is a strong indicator of a full bladder. The bladder, when full, displaces the uterus upward and to the side, preventing it from contracting correctly. Massage is reserved for a boggy uterus.

Choice B rationale

A deviated fundus, especially one located above the umbilicus, is a classic sign of bladder distention. A full bladder prevents the uterus from contracting and descending into the pelvis, which can lead to uterine atony and hemorrhage. Emptying the bladder allows the uterus to return to its midline position and contract effectively, a crucial step in preventing postpartum bleeding.

Choice C rationale

Elevating the head of the bed does not address the underlying cause of the deviated fundus. The physiological problem is a full bladder, which mechanically displaces the uterus. While raising the head of the bed may improve the client's comfort or breathing, it will not resolve the uterine displacement or the risk of postpartum hemorrhage associated with it.

Choice D rationale

While notifying the healthcare provider may be necessary if other interventions are ineffective, it is not the immediate first action. The nurse should first attempt the least invasive intervention to correct the problem. A deviated fundus is a common postpartum finding caused by a full bladder, and the first line of action is to have the client void, as this is a simple and effective solution.