What is the first action a nurse should take for a client in the fourth stage of labor?

In the fourth stage of labor, which is the critical recovery phase immediately following the delivery of the placenta, the primary focus for the nurse is to monitor the physiological well-being of the mother. Assessing the uterine fundus is essential because it helps to evaluate the tone and position of the uterus after childbirth.

A properly contracted uterus reduces the risk of postpartum hemorrhage, which is a significant danger during this stage. By palpating the fundus, the nurse can determine if it is firm and midline, indicating effective uterine contraction. If the fundus is boggy or displaced, it may require immediate intervention, such as fundal massage or other medical treatments. This assessment is fundamental to ensuring the mother's safety and stability after delivery.

While checking lochial flow, providing oral fluids, and examining the episiotomy site are also important aspects of postpartum care, they are secondary to the immediate need to assess uterine tone and prevent complications associated with uterine atony. Thus, assessing the uterine fundus is prioritized to maintain the mother's condition in this critical period.