During the fourth stage of labor, a client's blood pressure is 110/60 mmHg, pulse 90, and the fundus is firm, midline and halfway between the symphysis pubis and the umbilicus. Based on this data, which is the primary action by the nurse?
A) Massage the fundus.
B) Turn the client onto the left side.
C) Place the bed in the Trendelenburg position.
D) Continue to monitor.
Answer: D
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. The 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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