While assisting the client in the fourth stage of labor, the nurse determines the uterus is boggy and there is a moderate amount of vaginal bleeding. The priority nursing intervention is to

a. check for perineal lacerations
b. check for retained placental fragments
c. massage the uterus
d. prepare intravenous oxytocin


C
The physical stimulation of massaging the uterus should result in increased uterine contractility, with a resulting firmness of the uterus and decreased lochia. Perineal lacerations are not related to a boggy uterus. Checking for retained placental fragments may be necessary, but it is not a nursing action. Preparing intravenous oxytocin should already have taken place at the end of the third stage of labor.

Nursing

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Nursing

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Nursing