Question

The nurse assesses the fundus of a client 12 hours after delivery of a 7 lb 2 oz (3240 g) newborn. Which action should the nurse take if the fundus is noted to be approximately 1 cm above the umbilicus?

a) Notify the healthcare provider immediately.
b) Document the findings as normal for the time postpartum.
c) Assist the client with breastfeeding to stimulate uterine contractions.
d) Administer oxytocin to promote uterine involution.

Answer 1

The nurse should document the finding as normal for 12 hours postpartum since it indicates the expected involution process of the uterus, where breastfeeding can be beneficial.

Step-by-step explanation:

If the fundus is noted to be approximately 1 cm above the umbilicus 12 hours after delivery, the nurse should document the findings as normal for the time postpartum. This assessment suggests that involution is occurring as expected. Involution is the process by which the uterus gradually returns to its pre-pregnancy size and is facilitated by continued uterine contractions after birth.

Breastfeeding can help stimulate these contractions, but if the fundus assessment is normal, there is typically no need for immediate concern or additional interventions such as administering oxytocin unless there are other indications of a problem.