During the fourth stage of labor, the client's blood pressure (BP) is 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What should the nurse do?
1. Massage the fundus.
2. Continue to monitor.
3. Turn the client onto her left side.
4. Place the bed in Trendelenburg position.
2
Explanation:
1. The uterus should be midline and firm; massage is not necessary.
2. 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 BP and a slightly increased pulse.
3. A left lateral position is not necessary with a BP of 110/60 and a pulse of 90.
4. Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90.
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