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: 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: Administer terbutaline if the fundus is boggy is incorrect, as this action is contraindicated for a client who has a boggy fundus. Terbutaline is a tocolytic agent that can relax uterine contractions and worsen uterine atony and hemorrhage. The nurse should administer oxytocin or other uterotonic agents as prescribed to stimulate uterine contraction and prevent bleeding.

Choice B reason: Observe the lochia during palpation of fundus is correct, as this action can provide information about the amount, color, consistency, and odor of lochia. Lochia is the vaginal discharge that occurs after birth, which consists of blood, mucus, and tissue. The nurse should observe the lochia during fundal palpation and report any abnormal findings, such as excessive bleeding, large clots, foul smell, or infection.

Choice C reason: Document fundal height is correct, as this action can provide information about the progress of uterine involution. The fundus is the upper part of the uterus that can be palpated through the abdomen after birth. The nurse should document the fundal height in relation to the umbilicus and note any changes over time.

Choice D reason: Massage a firm fundus is incorrect, as this action is not necessary for a client who has a firm fundus. A firm fundus indicates adequate uterine contraction and involution and prevents excessive bleeding. The nurse should massage a boggy or soft fundus until it becomes firm and midline.

Choice E reason: Determine whether the fundus is midline is correct, as this action can provide information about the position of the uterus and bladder. The fundus should be midline and not displaced to either side. A deviated fundus can indicate bladder distension, which 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.