During the fourth stage of labor, the patient's assessment includes a BP of 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 is to:

Question

Quizplus · Accepted Answer

The patient's vital signs and fundal assessment are within normal limits during the fourth stage of labor, and no immediate action is necessary. However, continued monitoring is important to ensure that there are no changes in the patient's condition. Choices A and B are not indicated as there is no indication of hypotension or potential for supine hypotensive syndrome. Massage of the fundus may be necessary if it becomes boggy or deviates from midline, but it is not a priority action at this time.

During the Fourth Stage of Labor, the Patient's Assessment Includes