A nurse is completing an 8-hr 1&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

B) Assist the client to the bathroom to void:
A slightly boggy and displaced fundus to the right suggests a full bladder. A full bladder can displace the uterus and interfere with uterine contractions, leading to uterine atony. Therefore, the nurse should assist the client to the bathroom to void. Emptying the bladder will help the uterus to contract properly and return to its midline position.

A) Ask the client to rate her pain:
Pain assessment is important for overall client care but is not the priority in this situation. The displacement of the fundus suggests a physiological issue rather than pain being the primary concern.

C) Encourage the client to move to the left lateral position:
While positioning can assist with uterine displacement in some cases, the priority action is to address the full bladder. Once the client has emptied her bladder, the nurse can encourage a left lateral position to help optimize uterine contraction.

D) Encourage the client to perform Kegel exercises:
Kegel exercises are not indicated for addressing a boggy and displaced fundus. These exercises are typically used to strengthen the pelvic floor muscles, which can help with urinary incontinence and promote healing postpartum. However, they will not directly address the issue of a displaced fundus caused by a full bladder.

Answer: C. "You must be feeling scared and powerless."

Rationale:

A. "We have a neonatal unit here that's equipped to handle emergencies.
This response provides factual information but fails to acknowledge the client's emotional distress. While it may offer some reassurance, it does not directly validate the client's fears or foster therapeutic communication.

B. "Your pregnancy is advanced so your baby should be fine."
This statement offers premature reassurance without addressing the client’s emotional needs. It overlooks the potential risks of preterm birth at 32 weeks and may give a false sense of security, which could undermine trust if complications arise.

C. "You must be feeling scared and powerless."
This response reflects therapeutic communication by acknowledging the client’s emotional experience. It invites further discussion, demonstrates empathy, and builds a trusting relationship, which is essential during high-stress situations like preterm labor.

D. "Everyone worries about her baby when she's in labor."
This generalization minimizes the client’s individual feelings. It may make the client feel dismissed or that her concerns are not unique or important, which can hinder open, supportive communication.