The client delivered her first child vaginally seven hours ago. She has not voided since delivery. She has an IV of lactated Ringer's solution running at 100 ml/hr. Her fundus is firm, 1 FB ? U, to the right of midline
The best nursing action is to: 1. Massage the fundus vigorously.
2. Assesses the client's pain level.
3. Increase the rate of the IV.
4. Assist the client to the bathroom.
4
Rationale:
1. The location of the fundus and the time since delivery indicate that the bladder is distended. Emptying the bladder is the top priority.
2. This is not important at this time. Emptying the bladder is the top priority.
3. Emptying the bladder is the top priority. A distended bladder is an indication that hydration is adequate.
4. Emptying the bladder is the top priority.
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