Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void every 2 hours?
Select one:

Choice A Reason: Contact the physician, as it indicates early DIC. This is an incorrect answer that confuses a low pulse rate with a high pulse rate. DIC stands for disseminated intravascular coagulation, which is a life-threatening condition where abnormal clotting and bleeding occur simultaneously in the body. DIC can occur as a complication of postpartum hemorrhage, infection, or placental abruption. DIC can cause tachycardia (high pulse rate), not bradycardia (low pulse rate).

Choice B Reason: Contact the physician, as it is a first sign of postpartum eclampsia. This is an incorrect answer that misinterprets a low pulse rate as a sign of hypertension. Postpartum eclampsia is a condition where seizures occur in a woman who has preeclampsia or eclampsia after delivery. Preeclampsia and eclampsia are characterized by high blood pressure and proteinuria in pregnancy. Postpartum eclampsia can cause hypertension (high blood pressure), not hypotension (low blood pressure).

Choice C Reason: Document the finding as it is a normal finding at this time. This is because a pulse rate of 60 beats per minute is within the normal range for an adult and may reflect a physiological adaptation to the postpartum period. During pregnancy, the maternal blood volume and cardiac output increase, which can elevate the pulse rate. After delivery, these parameters gradually return to pre-pregnancy levels, which can lower the pulse rate.

Choice D Reason: Obtain an order for a CBC, as it suggests postpartum anemia. This is an incorrect answer that assumes that a low pulse rate is caused by anemia. Anemia is a condition where the red blood cell count or hemoglobin level is lower than normal, which can impair oxygen delivery to the tissues. Anemia can occur in the postpartum period due to blood loss during delivery or poor nutritional intake during pregnancy. Anemia can cause tachycardia (high pulse rate), not bradycardia (low pulse rate).

Choice A Reason: Assisting with the delivery of the placenta and ensuring that the fundus is contracted afterward. This is an appropriate action for the nurse to perform during the third stage of labor, as it helps complete the process of labor and prevent complications.

Choice B Reason: Palpating the woman's fundus for position and firmness. This is an action that is done after the delivery of the placenta, not during. It is important to monitor the fundal height, location, and consistency to assess uterine involution and bleeding.

Choice C Reason: Encouraging the woman to push with her contractions. This is an action that is done during the second stage of labor, not the third. The second stage of labor is the period from full cervical dilation to the birth of the baby. The nurse's role is to support and coach the woman to push effectively with her contractions.

Choice D Reason: Alleviating perineal discomfort with the application of ice packs. This is an action that is done after the delivery of the placenta, not during. It is a comfort measure that can reduce swelling, pain, and inflammation in the perineal area.