Maternity Nursing: Postpartum Q 19
On completing a fundal assessment, the nurse notes the fundus is situated on the client’s left abdomen. Which of the following actions is appropriate?
A. Ask the client to empty her bladder.
B. Straight catheterize the client immediately.
C. Call the client’s health provider for direction.
D. Straight catheterize the client for half of her uterine volume.
Correct Answer: A. Ask the client to empty her bladder.
A full bladder may displace the uterine fundus to the left or right side of the abdomen. Massage the fundus every 15 minutes during the first hour, every 30 minutes during the next hour, and then, every hour until the patient is ready for transfer.
Option B: Catheterization is unnecessary invasive if the woman can void on her own. Chart fundal height. Evaluate from the umbilicus using fingerbreadths. This is recorded as two fingers below the umbilicus (U/2), one finger above the umbilicus (1/U), and so forth. The fundus should remain in the midline. If it deviates from the middle, identify this and evaluate for a distended bladder.
Option C: Be able to recognize the difference between a full bladder and a fundus. Full bladders may actually cause postpartum hemorrhage because it prevents the uterus from contracting appropriately. Nerve blocks may alter the sensation of a full bladder to the patient and prevent her from urinating.
Option D: If at all possible, ambulate the patient to the bathroom. Urine output less than 300cc on initial void after delivery may suggest urinary retention. Document the fundal height and bladder status before the patient urinates. Reevaluate and document the fundal height and bladder status after the patient urinates to accurately document an empty bladder.