Question

A nurse is assessing a client in the immediate postpartum period. The fundus is boggy and deviated to the left of the umbilicus. Which of the following is the most appropriate intervention?

1) Assess lochia
2) Assist client to void
3) Reassess client in 30 min
4) Begin an oxytocin infusion

Answer 1

In the immediate postpartum period, a boggy fundus deviated to the side often indicates a full bladder or uterine atony. Assisting the client to void can help the uterus return to its normal position and prevent postpartum hemorrhage.

Step-by-step explanation:

A boggy fundus and deviation to the side following childbirth can be indicative of uterine atony or bladder distension, both of which can lead to postpartum hemorrhage. In this immediate postpartum assessment, the most appropriate intervention in this case would be to assist the client to void, option 2. A full bladder can displace the uterus and prevent it from contracting effectively. By assisting the client to void, the nurse can help the uterus return to its normal position and tone, reducing the risk of hemorrhage. If the fundus does not become firm after voiding, initiating a uterotonic such as oxytocin or manually massaging the uterus may be necessary to encourage contraction and firming of the fundus.