During the fourth stage of labor, a client's blood pressure is 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. The priority action of the nurse should be to:
1. Turn the client onto her left side.
2. Place the bed in Trendelenburg position.
3. Massage the fundus.
4. Continue to monitor.
4. Continue to monitor.
Rationale:
The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a slight drop in blood pressure and a slightly increased pulse. A left lateral position is not necessary with a BP of 110/60 and a pulse of 90. Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90. The uterus should be midline and firm; massage is not necessary.
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