During a routine postpartum assessment following a normal vaginal delivery, the nurse notes the fundus is firm but the level has changed from u-1 to u+1 . Which action would be appropriate prior to continuing the assessment?
a. Follow p.r.n. orders to insert a straight urinary catheter.
b. Massage the fundus vigorously until it des-cends below the umbilicus.
c. Request that the client ambulate to the bath-room to empty her bladder.
d. Start IV, and add 20 units of oxytocin ac-cording to unit protocols.
C
Request that the client ambulate to the bathroom to empty her bladder is an appropriate nursing action for a distended bladder, the most frequent cause of the fundus becoming displaced following a vaginal delivery. Inserting a catheter to drain the bladder is appropriate only if the mother is unable to urinate.
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