A nurse is collecting data from a postpartum client and notes the client's fundus is boggy and displaced to the right. Which of the following actions should the nurse take?

Choice A reason: While ice packs can help reduce swelling and discomfort, they are not essential for preventing infection.

Choice B reason: Sit on an inflatable donut to protect the perineum is incorrect, as this can increase pressure and blood flow to the perineum and delay healing. The nurse should advise the client to avoid sitting on hard or uneven surfaces and to use a pillow or a cushion for comfort.

Choice C reason: Perform hand hygiene before and after voiding is correct, as this can prevent contamination and infection of the perineal area. The nurse should instruct the client to wash their hands with soap and water or use an alcohol-based hand sanitizer before and after using the toilet.

Choice D reason: Blot the perineal area dry after voiding is correct, as this can keep the perineal area clean and dry and prevent irritation and infection. The nurse should instruct the client to use a clean, soft cloth or tissue and gently pat or blot the perineal area from front to back after voiding.

Choice E reason: Clean the perineal area from front to back is correct, as this can prevent bacteria from entering the vagina or urethra and causing infection. The nurse should instruct the client to use a peri-botle filled with warm water and squirt it over the perineal area from front to back after each voiding or bowel movement. The client should also change their perineal pad frequently and dispose of it properly.

Choice A reason: Massage the client's fundus is correct, as this is the first action the nurse should take according to the ABCDE priority framework. Saturating a perineal pad in 10 min indicates excessive bleeding and possible postpartum hemorrhage, which can compromise the client's airway, breathing, and circulation. Massaging the fundus can stimulate uterine contraction and reduce blood loss.

Choice B reason: Check the client's blood pressure is incorrect, as this is not the first action the nurse should take, although it is important to monitor for signs of shock. Checking the blood pressure does not address the cause of bleeding or prevent further blood loss.

Choice C reason: Administer oxytocin is incorrect, as this is not the first action the nurse should take, although it may be indicated later. Administering oxytocin requires a provider's order and may have adverse effects such as nausea,

vomiting, headache, or water intoxication. The nurse should first atempt to control bleeding by massaging the fundus and then administer oxytocin as ordered.

Choice D reason: Observe for pooling of blood under the butocks is incorrect, as this is not the first action the nurse should take, although it can help estimate blood loss. Observing for pooling of blood does not address the cause of bleeding or prevent further blood loss. The nurse should first atempt to control bleeding by massaging the fundus and then assess for other signs of hemorrhage.