A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?

Explanation

Choice A Reason:

Providing oxygen to the client via nonrebreather face mask is incorrect. Oxygen administration may be necessary if the client is hypoxic due to severe blood loss, but it is not the first action to address excessive vaginal bleeding.

Choice B Reason:

Emptying the client's bladder is incorrect. A full bladder can impede uterine contraction and contribute to postpartum hemorrhage. Emptying the bladder can help improve uterine tone and decrease bleeding. However, it is not the first action to take in the case of excessive vaginal bleeding.

Choice C Reason:

Administering oxytocin to the client is incorrect. Oxytocin is a uterotonic medication commonly used to promote uterine contraction and control postpartum bleeding. Administering oxytocin is an appropriate intervention for managing postpartum hemorrhage, but it may not be the first action to take.

Choice D Reason:

Massaging the client's fundus is correct. Massaging the client's fundus helps to stimulate uterine contractions, which can help control bleeding in the immediate postpartum period. Fundal massage is a standard intervention for managing postpartum hemorrhage and should be initiated promptly if excessive bleeding is noted.

Explanation

Choice A Reason:

"Do your contractions feel further apart?" This question does not directly assess the effectiveness of the hands-and-knees position in rotating the baby or relieving discomfort associated with occipitoposterior position. It focuses on the timing of contractions rather than the impact of the position change.

Choice B Reason:

"Are you feeling relief from your pelvic pressure?" Pelvic pressure is more associated with the descending fetus and the overall labor process. The hands-and-knees position is mainly intended to alleviate back pain caused by the fetus's occipitoposterior position, rather than pelvic pressure.

Choice C Reason:

"Has your back labor improved?" The hands-and-knees position is often used to help alleviate back labor, a common issue with a fetus in the occipitoposterior position. The pressure from the fetal head on the mother's spine can cause significant back pain, and the hands-and-knees position can help by shifting the fetal position slightly and relieving some of this discomfort.

Choice D Reason:

"Does that lessen your suprapubic pain?" Suprapubic pain is more related to the pressure of the descending fetus on the bladder and the lower uterus. While the hands-and-knees position may alleviate some discomfort, it is primarily aimed at relieving back labor caused by the occipitoposterior position, not suprapubic pain.