A nurse is caring for a client following a cesarean birth. The client tells the nurse that she is hungry. Which of the following actions should the nurse take first?

Choice A reason: Encourage the client to nurse more frequently so her milk will come in is incorrect, as this action is not related to the data collected by the nurse. The nurse notes that the client's breasts are soft, which indicates that the milk has not come in yet. This is normal and expected for a client who is 14 hr postpartum, as milk production usually begins around 72 to 96 hr after birth. The nurse should encourage the client to nurse frequently and effectively to stimulate milk production and prevent engorgement.

Choice B reason: Increase IV fluids is incorrect, as this action is not indicated by the data collected by the nurse. The nurse notes that the client's vital signs are within normal limits, except for a slight temperature elevation. Increasing IV fluids can cause fluid overload and electrolyte imbalance in the client. The nurse should maintain the IV fluids at the prescribed rate and monitor the client's intake and output.

Choice C reason: Ask the client to empty her bladder is correct, as this action is indicated by the data collected by the nurse. The nurse notes that the client's fundus is firm but slightly deviated to the right, which suggests bladder distension. A full bladder can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection. The nurse should assist the client to empty their bladder and reassess the fundal position.

Choice D reason: Report the client's temperature elevation is incorrect, as this action is not necessary for a slight temperature elevation in a postpartum client. The nurse notes that the client's temperature is 37.7° C (100° F), which is slightly above normal but within the range of expected findings for a postpartum client. A mild temperature elevation in the first 24 hr after birth can be due to dehydration, exertion, or hormonal changes and does not indicate infection. The nurse should encourage oral fluid intake and monitor the temperature every 4 hr.

Choice A reason: Perform fundal massage is incorrect, as this action is not indicated for a client who has a firm and midline fundus. Fundal massage is used to stimulate uterine contraction and prevent hemorrhage in clients who have a boggy or deviated fundus.

Choice B reason: Assist the client to ambulate is correct, as this action can promote lochia drainage and prevent pooling of blood in the vagina. The nurse should encourage the client to ambulate early and frequently after birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide assistance as needed.

Choice C reason: Check for blood under the client's butock is incorrect, as this action is not necessary for a client who has a small amount of lochia rubra on the perineal pad. Lochia rubra is normal and expected in the first few days after birth, and it indicates that the placental site is healing. The nurse should check for blood under the butock only if there is suspicion of excessive bleeding or concealed hemorrhage.

Choice D reason: Increase the rate of the IV fluids is incorrect, as this action is not indicated for a client who has a small amount of lochia rubra on the perineal pad. Increasing the rate of IV fluids can cause fluid overload and electrolyte imbalance in the client. The nurse should maintain the IV fluids at the prescribed rate and monitor the client's intake and output.