Difficulty: Medium
Average Score: 62%
Simulated
Passage / Scenario
Client who is 14 hr postpartum, breasts soft, fundus firm, slightly deviated to the right, moderate lochia rubra, temperature 37.7 C (100 F), pulse rate 88/min, respiratory rate 18/minA nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft, fundus firm, slightly deviated to the right, moderate 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 fundus deviated to the right suggests a full bladder, which can impede uterine contraction. Asking the client to empty her bladder is the priority to correct fundal position and prevent complications.