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?

Question

Quizplus · Accepted Answer

The client's vital signs and fundal assessment are within normal limits, indicating that the uterus is contracting well and the client is not experiencing excessive bleeding. Therefore, the nurse should continue to monitor the client. A) Massaging the fundus is not necessary at this time, as it is already firm and in the correct position. C) Turning the client onto her left side is not necessary unless she is experiencing hypotension, which is not indicated by her current blood pressure. D) Placing the bed in Trendelenburg position is not necessary and may actually increase the risk of bleeding.

During the Fourth Stage of Labor, the Client's Blood Pressure