It would be most important for a nurse caring for a mother and the infant in the fourth stage of labor to do which of the following?
a. Assess and massage the fundus every 15 minutes or more often if needed
b. Massage the uterus continuously
c. Administer oxytocin per protocol
d. Assess the patient for a distended bladder
ANS: A, C, D
The fourth stage of labor immediately follows the delivery of the placenta. The nurse should be assessing the fundus every 15 minutes for position, tone, and location. The provider may order oxytocin at this stage, and the nurse should assist the woman to the bathroom if she has a distended bladder which could interfere with the contraction of the uterus.
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