A nurse is monitoring a client following a cesarean birth 6 hr ago who received an IV bolus oxytocin immediately after birth but continues to have a boggy fundus. Which of the following should the nurse identify as the priority intervention?

A. Inspect the skin under the boot every 8 hr: Frequent skin assessment is critical for clients in Buck's traction because the traction boot or straps can cause pressure injuries, skin breakdown, or irritation. Checking the skin every 8 hours allows early detection of redness, sores, or areas of compromised circulation and prevents complications associated with prolonged immobility and pressure.

B. Assess the client's peripheral circulation every 12 hr: Peripheral circulation should be assessed more frequently than every 12 hours, typically every 1–2 hours initially, to detect early signs of neurovascular compromise such as cyanosis, pallor, coolness, or numbness. Waiting 12 hours could delay identification of circulation issues that may lead to tissue damage or compartment syndrome.

C. Ensure the weights are resting on the floor: Traction weights must hang freely to maintain proper alignment and effective traction. Allowing the weights to rest on the floor disrupts the pulling force, reducing traction effectiveness, increasing pain, and potentially worsening fracture displacement.

D. Remove the traction to allow the client to use the bathroom: Buck's traction should not be removed for routine activities such as toileting because interrupting traction can cause misalignment, increased pain, and delayed healing. Alternative methods, such as a bedside commode or urinal, should be used while maintaining traction integrity.

A. The client's shoulders are rounded slightly forward: Slightly rounded shoulders can indicate poor posture or musculoskeletal issues. While minor rounding is common, it is not a defining characteristic of a normal, standard gait and may reflect postural deviations.

B. The client's heels touch the ground before their toes: A standard gait involves initial contact with the heel, followed by a smooth rolling motion to the toes during the stance phase. This heel-to-toe pattern indicates normal foot mechanics and weight transfer, reflecting a healthy, functional gait for ADLs.

C. The client's dominant foot bears more weight: Unequal weight bearing between the dominant and non-dominant foot suggests an abnormal gait or musculoskeletal imbalance. In a normal gait, weight is distributed evenly between both lower extremities during walking.

D. The client looks at the floor when walking: Looking at the floor may indicate visual or balance issues, poor confidence, or gait instability. A standard gait typically involves a forward gaze with a stable, upright posture to maintain balance and coordination.