A nurse is caring for a client who has unrelieved episiotomy pain 8 hours following delivery. Which of the following actions should the nurse take? (Select onE.:

Choice A: Massaging a firm fundus is not necessary, as it indicates that the uterus is contracting well and preventing excessive bleedinG. Massaging a firm fundus may cause discomfort and increase the risk of infection.

Choice B: Determining whether the fundus is midline is an important action, as it indicates that the uterus is in the correct position and not displaced by a full bladder or hematomA. A deviated fundus may cause uterine atony and hemorrhagE.

Choice C: Observing the lochia during palpation of fundus is an important action, as it indicates the amount and type of vaginal discharge after delivery. The nurse should assess the color, odor, consistency, and quantity of lochia and report any abnormal findings.

Choice D: Documenting fundal height is an important action, as it indicates the involution of the uterus after delivery. The nurse should measure the distance from the symphysis pubis to the top of the fundus in centimeters and compare it with the expected findings.

Choice E: Administering terbutaline if the fundus is boggy is not an appropriate action, as terbutaline is a tocolytic agent that relaxes the uterine muscles and may worsen the bleedinG. The nurse should massage a boggy fundus until it becomes firm and notify the provider.

Choice A: Applying warm, moist soaks to the client's lower legs is not an effective intervention, as it can increase the swelling and the discomfort of the legs and interfere with the healing of the incision. The nurse should avoid applying heat to the legs and use compression stockings or pneumatic devices insteaD.

Choice B: Having the client ambulate frequently in the hallway is an effective intervention, as it can improve the blood circulation and prevent the formation of blood clots in the legs. The nurse should encourage the client to ambulate as soon as possible after the surgery and assist the client with the first ambulation.

Choice C: Keeping the client on bed rest is not an appropriate intervention, as it can increase the stasis and the coagulation of the blood and increase the risk of thrombophlebitis. The nurse should avoid prolonged bed rest and promote early mobilization of the client.

Choice D: Placing pillows under the client's knees while she is resting in bed is not an appropriate intervention, as it can impair the venous return and increase the pressure and the inflammation of the legs. The nurse should avoid placing anything under the client's knees and keep the legs slightly elevated and in a straight position.