The nurse's assessment of a woman 18 hours after birth indicates that the uterus is two fingerwidths above the umbilicus (u+2) and deviated to the right of the midline. What action should the nurse take first?
a. Notify the doctor immediately.
b. Massage the fundus to expel clots.
c. Assist the woman to empty her bladder.
d. Document findings and reassess in 30 mi-nutes.
C
The nurse should assist the woman to empty her bladder. A displaced uterus above the umbilicus and deviated to the right indicates an overfilled bladder. If she is unable and there are no orders for catheterization, the health care provider should be notified. This issue should be addressed right away, before the displacement causes the uterus to become boggy.
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