Level: Clinical
Difficulty: Medium
Subtopic: Postpartum assessment
NCLEX: Four hours after delivery, the client’s fundus is boggy above the umbilicus and deviated to the right. What shoul…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
Four hours after delivery, the client's fundus is boggy above the umbilicus and deviated to the right. What should the nurse do first?
Question
A. Massage the fundus and assess for bladder distention and excessive bleeding.
B. Document as normal and continue routine postpartum teaching.
C. Encourage strict bed rest without further uterine assessment.
D. Delegate all postpartum checks to UAP for the next 8 hours.
B. Document as normal and continue routine postpartum teaching.
C. Encourage strict bed rest without further uterine assessment.
D. Delegate all postpartum checks to UAP for the next 8 hours.
Rationale
Correct answer: A. Massage the fundus and assess for bladder distention and excessive bleeding.
Rationale: Boggy, deviated fundus suggests uterine atony and hemorrhage risk; fundal massage and assessment are priority.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Boggy, deviated fundus suggests uterine atony and hemorrhage risk; fundal massage and assessment are priority.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.