Difficulty: Medium
Average Score: 79%
Simulated
Passage / Scenario
Client 12 hr postpartum, fundus deviated to right, boggy, 2 cm above umbilicusA nurse is collecting data from a client who gave birth 12 hours ago. The nurse notes the fundus is deviated to the right, boggy, and 2 cm above the umbilicus. Which of the following actions should the nurse take first?
Correct answer
B
Rationale
A deviated, boggy fundus suggests a full bladder preventing uterine contraction. Assisting the client to void is the first step to correct this and reduce bleeding risk before considering medications or invasive measures.