RN Nursing · Normal Postpartum Care · Practice question
A nurse is caring for a client who is 6 hr. postpartum and finds the fundus slightly boggy, 3 cm above the umbilicus, and displaced to the right. Bleeding is not noted. Based on these findings, which of the following actions should the nurse take?
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✓
Assist the client to go to the bathroom.
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Encourage the client to move to the left lateral position.
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Encourage the client to perform Kegel exercises.
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Ask the client to rate her pain.
Answer & explanation
Correct: Assist the client to go to the bathroom.
In the postpartum period, a fundus that is displaced to the right and positioned above where it should be (higher than expected for 6 hours postpartum) strongly suggests bladder distension. A full bladder pushes the uterus upward and to the right, preventing normal uterine contraction and contributing to uterine boggyness. The priority intervention is to facilitate bladder emptying by assisting the client to the bathroom to void. Once the bladder is emptied, the uterus typically returns to the midline, descends to the appropriate level, and firms up. Encouraging the client to move to the left lateral position does not address the underlying cause of bladder displacement. Kegel exercises strengthen the pelvic floor but will not resolve the displaced, boggy fundus caused by bladder distension. Asking the client to rate her pain is a reasonable assessment step but does not address the primary problem. If the client is unable to void, bladder catheterization would be the next step. Because there is no active bleeding noted, immediate pharmacological uterotonic intervention is not the first action needed.
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