Within 3 hours, the fundus becomes boggy and is located 2 cm above the umbilicus and displaced to the right in the postpartum patient.
What is the priority nursing action?

Choice A rationale
Informing the obstetrician is important, but it is not the first action to take. The nurse should first try to address the issue at hand, which is a displaced and boggy uterus.
Choice B rationale
Straight catheterization of the patient could be necessary if the patient is unable to void. However, the first step should be to ask the patient to void.
Choice C rationale
Preparing the patient for manual removal of uterine clots is a more invasive procedure that should be considered if other measures, such as asking the patient to void or massaging the fundus, are not effective.
Choice D rationale
A full bladder can displace the uterus and prevent it from contracting properly. Asking the patient to void can help the uterus contract and reduce bleeding.

Choice A rationale
Hypothermia, decreased muscle tone, and a weak sucking reflex are not typically exhibited by newborns whose mothers are substance abusers. These symptoms could be indicative of other medical conditions.
Choice B rationale
Excessive sleep, a weak cry, and a diminished grasp reflex are not the most common behaviors exhibited by newborns of substance-abusing mothers.
Choice C rationale
Circumoral cyanosis, a hyperactive Babinski reflex, and constipation are not typically seen in newborns of substance-abusing mothers. These symptoms could be indicative of other medical conditions.
Choice D rationale
Newborns of substance-abusing mothers often exhibit decreased amounts of sleep, a hyperactive Moro reflex, and difficulty feeding. These symptoms are related to withdrawal from the substances the mother was using during pregnancy.