15 minutes later. The nurse completes another fundal check and vital sign assessment. She can wiggle her toes a small amount and she is having a small amount of discomfort rating pain at 1/10 on a 0-10 scale. She is shivering slightly
Her fundus is firm and at the umbilicus with a moderate amount of lochia rubra noted on her perineal pads. Indwelling catheter has 100 cc and she continues to have Lactated Ringers infusing at 125 ml/hr.
Blood pressure 115/74 mmHg, heart rate 89/min, respirations 19/min, temperature 36.0° C (97.3" Fj, oxygen saturation 98% on 2 ilters by nasal cannula. On a on a 0 to 10 scale. Shayna rates her pain at a 0.
After her fundus check Shayna states, "She looks so much like me when i was a baby! When can I start breastfeeding her?"
Which of the following actions should the nurse take?
O Place warm blankets on the client and infant.
O Assist the client with breastfeeding.
O Use pillows to position the mother and infant side-lying.
O Document positive bonding behaviors.
