Eight hours after a vaginal birth, the nurse palpates the client's uterine fundus 2 cm above the umbilicus and displaced to the right. The fundus is firm, and the lochia is moderate rubra. Which action should the nurse take first?
- AMassage the fundus and reassess the amount of lochia.
- BAssist the client to the bathroom to void, then reassess the fundus.
- CNotify the provider that the client may be having a postpartum hemorrhage.
- DIncrease the rate of the prescribed oxytocin infusion to firm the uterus.
Show answer and explanations
Answer
B
A: The fundus is already firm; its elevation and lateral displacement point to a distended bladder, so massage is unnecessary, painful, and does not correct the cause. B: Helping the client void can correct displacement; reassessment verifies response. C: The stated findings do not establish hemorrhage as the immediate explanation. D: Increasing oxytocin does not address the likely full bladder and requires an authorized plan.
A
The fundus is already firm; its elevation and lateral displacement point to a distended bladder, so massage is unnecessary, painful, and does not correct the cause.
B
Helping the client void can correct displacement; reassessment verifies response.
C
The stated findings do not establish hemorrhage as the immediate explanation.
D
Increasing oxytocin does not address the likely full bladder and requires an authorized plan.