When palpating the fundus of a woman on her first day postpartum, the nurse finds that the woman's uterus is higher than expected and is deviated to the right. She is not having excessive uterine bleeding

Question

Which is the priority nursing action for this client?
A) Notify the client's midwife of this condition.
B) Ask another nurse to assess the client to verify the findings.
C) Ask the client to void and then reassess fundal height.
D) Perform a straight catheterization on the client and then reassess fundal height.

Answer 1

Answer: C

The cause of a distended fundus in a recently delivered woman is likely due to a distended bladder causing a temporary upward displacement of the uterus. Having the woman empty her bladder and then reassessing fundal height is the priority action for the nurse to take at this time. If the client is unable to void, a straight catheterization to empty the bladder is indicated, after which fundal height would then be reassessed. The nurse would not notify the client about the data unless the assessment remains unchanged after the client voids. Asking another nurse to verify the assessment findings is not an appropriate action.