44. A nurse is performing a postpartum assessment on a client who is gravida 2, para 1 and delivered 6 hours ago by vacuum extraction with a fourth-degree laceration. The nurse notes that the fundus is firm, 2 fingerbreadths above the level of the umbilicus, and displaced to the right. Which action should the nurse take next?
. Assess the blood pressure for hypotension.
. Check the client for bladder distention.
. Determine whether an oxytocic drug was given.
. Massage the fundus to expel small clots.
Test-Taking Tip
The key to this question is that the fundus is deviated to the right. This finding is very common in bladder distention.
Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
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Answer 1 is incorrect because hypotension is a late sign of postpartum hemorrhage. Answer 2 is correct because the likely reason for the fundus to be higher than expected and deviated to the right is bladder distention. If the bladder is not emptied, a postpartum hemorrhage can occur. Answer 3 is incorrect because the likely reason for the fundus to be higher than expected and deviated to the right is bladder distention. Administration of oxytocic agents will not resolve her bladder distention. Answer 4 is incorrect because massaging the fundus to expel small clots will not resolve her bladder distention.