The nurse is assessing a client who gave birth 72 hours ago to a healthy infant and is formula-feeding only.

The nurse notices that both of the client's breasts are swollen, warm, and tender on palpation.

What is the most appropriate nursing intervention for this client?

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.

Fetal heart rate interpretation involves analyzing the baseline, variability, and presence of accelerations or decelerations. Knowledge of the categories defined by obstetric guidelines is necessary to determine if the tracing is reassuring or requires corrective nursing interventions.

Choice A rationale

Decreasing oxytocin is an intervention for Category II or III tracings involving tachysystole or late decelerations. If the strip shows reassuring patterns, such as a normal baseline and moderate variability, reducing the induction agent is unnecessary and slows labor.

Choice B rationale

Continuing to monitor is appropriate for a Category I tracing, which includes a baseline of 110 to 160 beats per minute, moderate variability, and no concerning decelerations. These signs indicate fetal well-being and adequate oxygenation during labor contractions.

Choice C rationale

A cesarean section is reserved for non-reassuring fetal status that does not respond to intrauterine resuscitation. If the strip indicates normal fetal heart rate patterns, surgical intervention is not indicated and would pose unnecessary risk to the client.

Choice D rationale

Tocolytics are medications used to stop contractions during preterm labor or uterine hyperstimulation. Their use is not indicated when a strip is normal, as the goal is to allow labor to progress safely while monitoring fetal responses.