The nurse is assessing the urinary output of a patient 4 hours after a caesarean birth. The patient weighs 68 kg and the indwelling catheter bag measures 125 mL of urine. Which action will the nurse include in the plan of care?

The correct order is: b, a, d, c

1. b) Position the patient in a supine position: The first step is to ensure the patient is in a supine position, which is lying on their back. This position provides the best access and visibility for the nurse to assess the fundus effectively. Ensuring the patient is comfortable and relaxed in this position is crucial before beginning the assessment.
2. a) Place one hand on the lower segment of the uterus: The next step involves placing one hand on the lower segment of the uterus. This helps to stabilize the uterus and provides support while the nurse palpates the fundus. It also prevents any excessive movement that could cause discomfort or complications.
3. d) Press at the level of the umbilicus to palpate the fundus: The nurse then presses at the level of the umbilicus (belly button) to palpate the fundus. The fundus is the top portion of the uterus, and assessing its position and firmness provides important information about the postpartum recovery process.
4. c) Gently massage the fundus in a circular motion: Finally, the nurse gently massages the fundus in a circular motion. This action helps to ensure the uterus remains firm and can help in preventing postpartum haemorrhage. If the fundus is not firm, the massage can stimulate uterine contractions to firm it up.

Choice A reason: The statement that "Semi-Fowler's is the safest position for pushing" is not necessarily appropriate because the best position for pushing can vary from one woman to another. There is no single safest position universally recommended for all labouring women. The choice of position should be individualized based on the woman's comfort, progress of Labor, and any specific medical considerations. The Semi-Fowler's position involves lying semi-upright, which might be suitable for some but not for everyone.

Choice B reason: Advising the patient to "choose a position you feel most comfortable" is appropriate because it empowers the woman to listen to her body and adopt a position that feels natural and effective for her. Comfort plays a crucial role in the effectiveness of pushing and the overall Labor experience. This approach promotes a sense of control and autonomy for the labouring woman and aligns with best practices in patient-cantered maternity care.

Choice C reason: Suggesting that "sitting with your head elevated on two pillows makes pushing easier" may not be the best advice for every labouring woman. While this position might work for some, it is not universally effective or recommended. Labor positions should be flexible and adaptive to the individual's needs and comfort. Blanket recommendations can overlook the diversity of experiences and preferences among labouring women.

Choice D reason: Telling the patient that "it is normal if you're having a bowel movement" might address a concern some women have during Labor. However, it does not directly guide the woman on effective pushing positions. While it can be reassuring to mention that a bowel movement can occur during pushing, this statement alone is not sufficient as a primary piece of advice for managing the second stage of Labor.