The nurse is caring for a client who delivered 6 hours ago.
The client’s uterus is boggy and is displaced above and to the right of the umbilicus. What action should the nurse take?

Choice A rationale

Leakage of clear fluid from the breasts towards the end of the second trimester into the third trimester is normal. This fluid is colostrum, a precursor to breastmilk, and its presence indicates breast development in preparation for lactation.

Choice B rationale

An average weight gain during pregnancy is 25 to 35 pounds. In the second trimester, a woman should be gaining about 1 pound per week. A weight gain of 20 pounds by 20 weeks indicates the client is on track or has even gained slightly more than expected. However, further evaluation is important as excessive weight gain in pregnancy might be indicative of underlying conditions such as preeclampsia or gestational diabetes.

Choice C rationale

Fetal movement, also known as quickening, is a normal and expected occurrence around 18-20 weeks' gestation. It is a positive sign of fetal development and well-being.

Choice D rationale

Fundal height is the measure from the pubic symphysis to the top of the uterus. It is an indicator of fetal growth. A fundal height of 20cm at 20 weeks gestation suggests the pregnancy is progressing normally and the baby is growing appropriately.

The correct answer is calculated as follows:

Step 1: Identify the total amount of oxytocin in the IV bag. The bag contains 20 units of oxytocin in 1 liter (or 1000 mL) of lactated Ringer’s solution.

Step 2: Convert the oxytocin units to milliunits. 1 unit = 1000 milliunits, so 20 units = 20,000 milliunits.

Step 3: Calculate the concentration of the oxytocin solution in milliunits/mL. Divide the total amount of oxytocin in milliunits by the total volume of the solution in mL.

So, 20,000 milliunits ÷ 1000 mL = 20 milliunits/mL.

Step 4: Calculate the infusion rate in mL/hour. The prescription is for an infusion rate of 2 milliunits/min. Since the concentration of the solution is 20 milliunits/mL, we divide the prescribed rate by the concentration to get the rate in mL/min. So, 2 milliunits/min ÷ 20 milliunits/mL = 0.1 mL/min.

Step 5: Convert the infusion rate to mL/hour. Multiply the rate in mL/min by the number of minutes in an hour. So, 0.1 mL/min × 60 min/hour = 6 mL/hour. Therefore, the nurse should program the infusion pump to deliver 6 mL/hour.