A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider?

Choice A rationale:

Assisting the client to void is a priority intervention in this situation. A full bladder can displace the uterus and prevent it from contracting effectively, leading to a boggy and high- positioned fundus. After the client empties her bladder, the nurse should reassess the fundus to ensure it has descended to its appropriate location, which is usually at or just below the level of the umbilicus.

Choice B rationale:

Documenting the findings as within normal limits is incorrect because a firm, displaced fundus that is 3 cm above the umbilicus is not considered normal. This finding indicates that the uterus is not contracting adequately, and the nurse should take appropriate actions to address the issue.

Choice C rationale:

Gently massaging the client's fundus is not the correct intervention in this case. Massaging a firm fundus could cause uterine irritation and should be avoided. Instead, the nurse should encourage the client to empty her bladder, which often helps the uterus contract and descend to its proper position.

Choice D rationale:

Encouraging the client to ambulate may be helpful in some cases to promote uterine contractions and involution. However, in this situation, the priority is to address the full bladder, as it is a common cause of a displaced and high fundus shortly after delivery.

Choice A rationale:

Before an amniocentesis, it is essential for the client to empty their bladder. A full bladder can interfere with the procedure, as it may obstruct the needle's entry into the uterus and increase the risk of accidental bladder puncture.

Choice B rationale:

Nothing by mouth (NPO) for 4 hours is not necessary for an amniocentesis. It is a relatively simple and quick procedure that does not require fasting.

Choice C rationale:

Ingesting 3 liters of water is not indicated before an amniocentesis. While some ultrasound examinations may require a full bladder, this is not the case for an amniocentesis.

Choice D rationale:

Nipple stimulation is not relevant or necessary before an amniocentesis. Nipple stimulation can trigger uterine contractions, which might be undesirable before the procedure, especially if the client is not in labor.