Difficulty: Medium
Average Score: 92%
Simulated
Passage / Scenario
A client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicusA nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?
Correct answer
C
Rationale
The correct answer is C: Have the client urinate. This is because the fundus being displaced to the right and firm with a height of two fingerbreadths above the umbilicus indicates a full bladder pushing the fundus. Having the client urinate will help empty the bladder, allowing the fundus to move back to the midline and descend.
Rationale for incorrect answers:
A: Insert a urinary catheter - Not necessary at this time as the priority is to have the client urinate to relieve the bladder pressure.
B: Massage the fundus - Massaging the fundus is not indicated in this situation where the fundus is firm and displaced due to a full bladder.
D: Administer an analgesic - There is no indication for administering an analgesic in response to the fundal position described.
Rationale for incorrect answers:
A: Insert a urinary catheter - Not necessary at this time as the priority is to have the client urinate to relieve the bladder pressure.
B: Massage the fundus - Massaging the fundus is not indicated in this situation where the fundus is firm and displaced due to a full bladder.
D: Administer an analgesic - There is no indication for administering an analgesic in response to the fundal position described.