A nurse is performing a postpartum assessment 30 minutes after a vaginal delivery. Which of the following actions indicates that the nurse is performing the assessment correctly?
a. The nurse measures the fundal height in relation to the symphysis pubis.
b. The nurse monitors the client's central venous pressure.
c. The nurse assesses the client's perineum for edema and ecchymoses.
d. The nurse performs a sterile vaginal speculum exam.
ANS: c
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a. The fundal height should be measured in relation to the umbilicus.
b. The central venous pressure is not monitored during postpartum assessments.
c. The nurse should assess the perineum for signs of edema and ecchymoses.
d. If a speculum exam were needed, a physician or midwife would perform the procedure. Speculum exams are rarely needed postpartum.
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