A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

A fundus that is firm but deviated to the right at 14 hours postpartum is the classic sign of a full bladder displacing the uterus. When the bladder is distended, it pushes the uterus upward and to the side, which can also impair uterine contraction and increase the risk of postpartum hemorrhage. Asking the client to void and then reassessing fundal position is the priority nursing action. A temperature of 37.7°C (100°F) within the first 24 hours postpartum is considered a normal physiological response to the stress of labor and delivery and does not need to be reported; temperatures above 38°C (100.4°F) persisting beyond 24 hours would be more concerning. Increasing IV fluids is not indicated because the underlying problem is urinary retention, not dehydration, and adding fluid could worsen bladder distension. Encouraging more frequent nursing to stimulate milk production is not appropriate at this time; breasts are expected to be soft at 14 hours postpartum as milk typically comes in around days 2–4, and this does not address the acute finding. The moderate lochia rubra is normal for this stage. The single most important intervention is addressing the full bladder, which will likely return the fundus to midline.