Question

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88./min, respiratory rate 18/min. Which of the following actions should the nurse perform?

A. Encourage the client to nurse more frequently so her milk will come in.
Rationale: This is not an appropriate action; the breasts are expected to be soft after delivery.
B. Report the client's temperature elevation.
Rationale: A temperature up to 38° C (100.4° F) following delivery is often the result of dehydration. Once the client is hydrated, the temperature is expected to return to normal.
C. Ask the client to empty her bladder.
Rationale: Whenever the funds is deviated from the midline, a full bladder should be considered as a potential cause. A full bladder could result in complications such as uterine atony or infection.
D. Increase IV fluids.
Rationale: Increasing the IV fluids is not indicated for this client.

Answer 1

The nurse should ask the client to empty her bladder, as the deviated fundus suggests a full bladder could be at play, potentially leading to complications if not addressed.

Step-by-step explanation:

In the case of the client who is 14 hours postpartum with a finding of breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88/min, and respiratory rate 18/min, the most appropriate action for the nurse to perform is to ask the client to empty her bladder. The fundus being deviated to the right suggests a full bladder, which might cause complications such as uterine atony or infection. Encouraging the client to nurse more frequently is unnecessary at this time since soft breasts are expected, and the slight temperature elevation is not unusual, as it may be a result of dehydration and not necessarily indicative of infection.