Question

The nurse cares for a client 12 hours after the delivery of a 7 lb 2 oz (3,240g) newborn. Which action should the nurse take if the fundus is noted to be approximately 1 cm above the umbilicus?

a) Document the finding as normal.
b) Massage the fundus to promote contractions.
c) Encourage the client to empty her bladder.
d) Notify the healthcare provider immediately.

Answer 1

If the fundus is approximately 1 cm above the umbilicus 12 hours postpartum, the nurse should document this as a normal finding, reflective of the involution process. It is also beneficial to encourage the client to empty her bladder for accurate fundus assessment.

Step-by-step explanation:

If the fundus is noted to be approximately 1 cm above the umbilicus 12 hours after the delivery of a newborn, the appropriate action for the nurse to take is to document the finding as normal. This is reflective of the ongoing process of involution, where postpartum uterine contractions work to return the uterus to its pre-pregnancy size. During this period, the fundus is typically expected to be approximately at the level of the umbilicus or slightly above immediately after delivery and should descend approximately 1 to 2 cm every 24 hours.

Furthermore, it's important to consider other contributing factors such as bladder fullness, as a full bladder can displace the uterus and make the fundus appear higher. Therefore, it may also be beneficial to encourage the client to empty her bladder, which can allow for a more accurate assessment of the fundus position.