Health Promotion and Maintenance Q 37
When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:
A. Check the client for bladder distention
B. Assess the blood pressure for hypotension
C. Determine whether an oxytocic drug was given
D. Check for the expulsion of small clots
Correct Answer: A. Check the client for bladder distention
If the fundus of the client is displaced to the side, this might indicate a full bladder. The next action by the nurse should be to check for bladder distention and catheterize, if necessary. The uterus continues to contract after delivery, and its size decreases rapidly as estrogen and progesterone levels diminish. Immediately after delivery, the upper portion of the uterus, known as the fundus, is midline and palpable halfway between the symphysis pubis and the umbilicus.
Option B: Primary responsibilities of nurses in postpartum settings are to assess postpartum patients, provide care and teaching, and if necessary, report any significant findings. It is imperative for nurses to distinguish between normal and abnormal findings and to have a clear understanding of the nursing care necessary to promote patients’ health and well-being.
Option C: By approximately one-hour post-delivery, the fundus is firm and at the level of the umbilicus. The fundus continues to descend into the pelvis at the rate of approximately one centimeter (finger-breadth) per day and should be nonpalpable by two weeks postpartum.
Option D: These are actions that relate to postpartum hemorrhage. After delivery, the endometrial surface of the uterus is shed via the vagina. The shedding endometrium is known as lochia. Menstruation does not typically return until 12 weeks or later. However ovulation can return prior to menses, and it is important for healthcare providers to discuss family planning with patients during the early postpartum period in order to prevent undesired pregnancies.