Maternity Nursing: Postpartum Q 34
A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following?
A. Ask the client to turn on her side.
B. Ask the client to lie flat on her back with the knees and legs flat and straight.
C. Ask the mother to urinate and empty her bladder.
D. Massage the fundus gently before determining the level of the fundus.
Correct Answer: C. Ask the mother to urinate and empty her bladder.
Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. The postpartum recovery period covers the time period from birth until approximately six to eight weeks after delivery. This is a time of healing and rejuvenation as the mother’s body returns to prepregnancy states.
Option A: The nurse may place the woman in a supine position or Semi Fowlers position to avoid a decrease in her blood pressure for fundal assessment. Patients or a family member can be taught to assess the firmness of the fundus and to provide massage in the event of a boggy uterus or excessive bleeding. Patients are encouraged to void before palpation of the uterine fundus because a full bladder displaces the uterus and can lead to excessive bleeding.
Option B: When the nurse is performing a fundal assessment, the nurse asks the woman to lie flat on her back with the knees flexed.
Option D: Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm. By approximately one hour post-delivery, the fundus is firm and at the level of the umbilicus.