A nurse is caring for a client who is requesting to go to the bathroom immediately after a vaginal birth. Which of the following actions should the nurse take?

Choice A reason: Inform the client that she can go to the bathroom whenever needed is incorrect, as this action can put the client at risk of injury or complications. The client may experience orthostatic hypotension, dizziness, weakness, or bleeding after a vaginal birth, which can impair their ability to ambulate safely and independently. The nurse should assist the client to the bathroom and monitor their vital signs and lochia.

Choice B reason: This is the correct action. The nurse should assess the client for any residual effects of analgesia, such as dizziness or unsteadiness, which could increase the risk of falls if the client tries to get up.

Choice C reason: Advise the client to remain in bed for the next few hours is incorrect, as this action can increase the risk of bladder distension, infection, or thrombosis. The nurse should encourage and assist the client to ambulate early and frequently after a vaginal birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide support as needed.

Choice D reason: While assisting the client is a good approach, it is important to first evaluate her condition to ensure it is safe for her to get out of bed. If she has been assessed and is deemed safe to ambulate, assisting her to the bathroom with support might be appropriate. However, the initial step is to assess her condition.

Choice A reason: Wear a nipple shield is incorrect, as this recommendation is not indicated for a client who has engorged breasts. A nipple shield is a thin, flexible device that covers the nipple and areola and can help with latch problems, flat or inverted nipples, or sore nipples. However, a nipple shield can also reduce milk transfer, stimulate less milk production, and cause nipple confusion or preference.

Choice B reason: Express milk from both breasts is correct, as this recommendation can help relieve engorgement and maintain milk production. Engorgement is a normal and expected phenomenon that occurs when the milk comes in, usually around 72 to 96 hr after birth. Engorgement can cause breast fullness, tenderness, warmth, and hardness. The nurse should advise the client to express milk from both breasts by breastfeeding frequently and effectively or by using a breast pump or hand expression.

Choice C reason: Obtain a prescription for an antibiotic is incorrect, as this recommendation is not indicated for a client who has engorged breasts. An antibiotic is used to treat mastitis, which is an infection and inflammation of the breast tissue that can cause redness, pain, swelling, warmth, and fever in the affected breast. The nurse should assess the client for signs of mastitis and report any abnormal findings to the provider.

Choice D reason: Apply a heating pad to her breasts is incorrect, as this recommendation can worsen engorgement and cause discomfort. A heating pad can increase blood flow and swelling in the breasts, which can impair milk flow and increase pain. The nurse should advise the client to apply cold compresses or cabbage leaves to her breasts to reduce inflammation and discomfort.