A client is in the fourth stage of labor. Which set of assessments is the highest priority at this time?
ExplanationStage four is the first 2 to 4 hours postpartum. At this time, the nurse should frequently assess maternal vital signs, the fundus, bladder status, and lochia. The vital signs indicate the ability of the client to transition from pregnancy to postpartum and the physical status of the mother. The maternal fundus should remain firm, midline, and at the umbilicus or lower. A bladder that is distended may displace the normal fi rm uterus and cause hemorrhage. The lochia is assessed for color, odor, and amount postpartum. Assessment of the mother’s ability to push, hydration, emotional stability, contraction patterns, and fetal heart tones is important in stages one and two. Maternal vital signs will be assessed during all stages of labor. Maternal emotional status and infant bonding and feeding preferences are lower priorities than the physical well-being of the mother.
