Difficulty: Medium
Average Score: 77%
Simulated
Passage / Scenario
A client who had a vaginal delivery 1 day agoA nurse is caring for a client who had a vaginal delivery 1 day ago. The nurse determines that the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first?
Correct answer
C
Rationale
A deviated, elevated fundus suggests bladder distention, so assisting the client to void is the priority to aid uterine contraction, before notifying the provider or other actions.