A client at 37 weeks gestation is admitted with complaints of fever, pain and swelling in her groin, and contractions every 15 minutes.
The nurse, when assessing the client’s perineum, found erythematous lesions on the vulva that look like herpes. The nurse anticipates the patient’s treatment regimen to include which of the following?

Choice A rationale
Inserting an indwelling urinary catheter is not the immediate next step. While it may be necessary in some cases, the priority is to address the client’s excessive bleeding, which is a sign of postpartum hemorrhage.
Choice B rationale
Administering oxytocin by continuous IV infusion is a common intervention for postpartum hemorrhage. However, it is not the immediate next step. The nurse should first attempt to massage the client’s fundus to promote contractions and control bleeding.
Choice C rationale
Massaging the client’s fundus is the correct next step. The client’s symptoms indicate postpartum hemorrhage, a serious condition that can lead to shock and other complications. Fundal massage often helps the uterus contract and can stop the bleeding.
Choice D rationale
Tilting the client onto her right side with her legs elevated to at least 30 degrees is not the immediate next step. This position can help improve venous return but does not directly address the cause of the client’s symptoms.

Choice A rationale
Administering oxygen via a nasal cannula is not the appropriate response to a client experiencing tingling fingers during pattern-paced breathing. This symptom is not indicative of hypoxia.
Choice B rationale
Having the client tuck her chin to her chest can help alleviate the tingling sensation. This position can help reduce hyperventilation, which is often the cause of the tingling.
Choice C rationale
Assisting the client to breathe into a paper bag is not the appropriate response to a client experiencing tingling fingers during pattern-paced breathing. This action is typically used to treat hyperventilation, but it is not the first-line intervention.
Choice D rationale
Instructing the client to increase her respiratory rate to more than 42 breaths per minute is not the appropriate response to a client experiencing tingling fingers during pattern-paced breathing. This could exacerbate the problem by causing further hyperventilation.