A nurse is performing a postpartum assessment 30 minutes after a vaginal delivery. Which of the following actions indicates that the nurse is performing the assessment correctly?

Choice A rationale A sterile vaginal speculum examination is not a routine component of the immediate postpartum assessment (first hour after birth). This invasive procedure is typically reserved for evaluating lacerations or the cervix if bleeding is excessive or pathology is suspected, not for a standard 30-minute assessment, which focuses on hemorrhage and recovery. Choice B rationale The fundal height is measured in relation to the umbilicus immediately postpartum, not the symphysis pubis. Within the first hour after delivery, the uterine fundus should be firm and located at or near the level of the umbilicus (U/U to U/1, meaning at or one fingerbreadth below the umbilicus), which indicates proper uterine involution and contractility. Choice C rationale Assessing the client's perineum for edema (swelling) and ecchymoses (bruising) is a crucial and correct action. Edema and ecchymosis indicate soft tissue trauma from the delivery, increasing the risk for hematoma formation and discomfort, and must be monitored to ensure timely intervention for complications. Choice D rationale Monitoring the client's central venous pressure (CVP) is a technique used in critical care settings to assess fluid status and cardiac function. It is not a part of the standard postpartum assessment for a healthy woman after a routine vaginal delivery, which focuses on vital signs, fundus, lochia, and perineum.