Question

A nurse assessing a client in the fourth stage of labor notes that the uterine fundus is firmly contracted and is midline at the level of the umbilicus. On the basis of this finding, the nurse most appropriately:

a) Encourages the client to ambulate
b) Administers pain medication as ordered
c) Assesses the client's bladder for distention
d) Documents the normal uterine fundal position

Answer 1

The nurse should document the normal uterine fundal position in the assessment of a client in the fourth stage of labor with a firmly contracted uterus that is midline at the level of the umbilicus.

Step-by-step explanation:

Based on the nurse's assessment, the firm contraction and midline position of the uterine fundus at the level of the umbilicus indicate that the uterus is in a normal and expected position during the fourth stage of labor. This finding suggests that the client's labor is progressing as expected.

In response to this finding, the most appropriate action for the nurse is to document the normal uterine fundal position. This finding indicates that the client's labor is progressing well, and there is no immediate need for interventions such as encouraging the client to ambulate or administering pain medication as ordered.

Assessing the client's bladder for distention is also an important nursing intervention during labor, but it may not be as urgent in this particular scenario as the client's uterus has a normal fundal position.