A nurse is caring for a client who gave birth 2 hours ago.
The nurse notes that the client’s blood pressure is 60 mm Hg. Which of the following actions should the nurse take first?

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
While it is important to monitor a client’s temperature regularly, especially if they have a fever, simply checking the client’s temperature in 4 hours is not an adequate response to a temperature of 38.9°C (102°F) in a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. This could indicate an infection, which could be dangerous for both the mother and the baby.
Choice B rationale
Administering glucocorticoids intramuscularly is not typically the first-line treatment for a fever in a pregnant woman. Glucocorticoids are often used to accelerate fetal lung maturity in preterm labor, but they are not typically used to treat infections or fevers.

Choice C rationale
Preparing the client for an emergency cesarean section may be necessary if the client’s condition worsens or if there are other complications, but it is not the immediate response to a fever. The first step would be to identify and treat the cause of the fever, which could be an infection.
Choice D rationale
Administering acetaminophen orally is an appropriate nursing action for a client with a fever. Acetaminophen can help to reduce the client’s fever and make her more comfortable. However, it is also important to identify and treat the underlying cause of the fever, which could be an infection.