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?

A. encourage the client to void
B. assess for the amount and character of the lochia
C. bring the infant to the mother for breastfeeding
D. chart the results in the patient's chart

Answer 1

The most important action for the nurse to take is to assess for the amount and character of the lochia.

Step-by-step explanation:

When a nurse notes that the fundus is approximately 1 cm above the umbilicus 12 hours after delivery of a 3,200 g infant, the most important action for the nurse to take is to assess for the amount and character of the lochia. Lochia is the postpartum vaginal discharge that consists of uterine lining cells, erythrocytes, leukocytes, and other debris. By assessing the lochia, the nurse can monitor for any signs of excessive bleeding or infection, which are important to identify and address promptly to ensure the mother's well-being.