Question

The nurse cares for a patient 12 hours after delivery of a 3,200 g infant. The nurse notes that the fundus is approximately 1 cm above the umbilicus. It is most important for the nurse to take which of the following actions?

- encourage the client to void
- assess for the amount and character of the lochia
- bring the infant to the mother for breastfeeding
- chart the results in the patient's chart

Answer 1

After a nurse observes that the fundus is around 1 cm above the umbilicus in a postpartum patient, it is critical to encourage urination, assess the lochia for potential complications, support breastfeeding to aid uterine contractions, and document these observations for ongoing patient care.

Step-by-step explanation:

The question is asking what the most important action is for a nurse to take after noting that a patient's fundus is approximately 1 cm above the umbilicus 12 hours postpartum. In this case, the nurse should encourage the client to void, assess the amount and character of the lochia, bring the infant to the mother for breastfeeding, and chart the results in the patient's chart.

• Encouraging the client to void can help with the involution process of the uterus after childbirth.
• Assessing the lochia provides crucial information about the mother's recovery and can reveal signs of excessive blood loss or infection.
• Bringing the infant to the mother for breastfeeding can help the uterus contract and reduce bleeding.
• It's also essential to chart the findings for record-keeping and further assessment.