The nurse is reviewing the client's telemetry printout. Which of the following cardiac components should the nurse identify as the role of the P wave?

Rationale:

A. Encourage the client to move to the left lateral position is incorrect because while positioning can help comfort and circulation, it does not correct uterine displacement or a boggy fundus. The primary concern is uterine atony due to bladder distention, not positioning.

B. Encourage the client to perform Kegel exercises is incorrect because Kegel exercises strengthen pelvic floor muscles but do not address uterine atony or displacement. They are appropriate for long-term pelvic floor recovery, not acute fundal management.

C. Assist the client to the bathroom to void is correct because a boggy and displaced fundus often indicates a full bladder, which prevents the uterus from contracting effectively. Urinary retention can lead to uterine atony and postpartum hemorrhage. Having the client void or using a catheter if necessary allows the fundus to return to midline and become firm, reducing bleeding risk.

D. Ask the client to rate her pain is incorrect because while assessing pain is part of routine postpartum care, it does not address the immediate priority of correcting fundal atony and displacement, which can lead to postpartum hemorrhage if left uncorrected.

Rationale:

A. Plan to administer a plain water enema and maintain contact precautions is incorrect because pyloric stenosis is not an infectious condition and does not require contact precautions. Enemas, especially plain water enemas, are contraindicated in infants due to the risk of causing severe electrolyte imbalance and water intoxication. This intervention does not address the underlying problem of vomiting and dehydration.

B. Monitor the infant for dehydration and electrolyte imbalance is correct because infants with pyloric stenosis experience projectile, non-bilious vomiting, which leads to significant loss of fluids and gastric electrolytes. This commonly causes metabolic alkalosis, hyponatremia, and hypokalemia. The infant in the scenario already shows signs of dehydration, including dry mucous membranes and a depressed anterior fontanel, making fluid and electrolyte monitoring the top priority. Restoring hydration and correcting electrolyte disturbances are essential before any surgical intervention (pyloromyotomy).

C. Measure the infant's head circumference and weigh the infant is incorrect because although weight monitoring is part of routine assessment, head circumference measurement is not a priority in the context of acute dehydration from pyloric stenosis. The immediate concern is stabilizing fluid and electrolyte status.

D. Offer the infant small, frequent feedings of thickened liquids is incorrect because infants with pyloric stenosis are typically NPO until after surgical correction. Continuing oral feedings would worsen vomiting and further dehydrate the infant. Feeding modifications are not an appropriate intervention at this stage.