The nurse determines the fundus of a postpartum patient to be boggy. Initially, the nurse should:
1. Document the findings.
2. Catheterize the patient.
3. Massage gently and reassess.
4. Call the physician immediately.
3
Rationale 1: Documenting the findings would come after massage, reassessment, and evaluation.
Rationale 2: Catheterizing the patient might be indicated if assessment reveals a full bladder and inability to void, but not as an initial intervention.
Rationale 3: Massaging gently and reassessing would be the initial intervention to prevent postpartum hemorrhage.
Rationale 4: Calling the physician immediately is not necessary until more data are obtained.
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