Difficulty: Medium
Average Score: 76%
Simulated
Passage / Scenario
client, 14 hr postpartum, boggy fundus, large lochia rubraA nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft, fundus boggy 4 fingerbreadths above the umbilicus and deviated to the right, large lochia rubra, temperature 37.7°C (100°F), pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?
Correct answer
A
Rationale
A full bladder is the likely cause of the deviated, boggy fundus; emptying it is the first action to reduce bleeding.