Question

Two hours after giving birth, a client's physical assessment includes BP 86/40; TPR 98/100/22; fundus firm, four fingerbreadths above umbilicus; small spots of lochia rubra on perineal pad; and distended bladder. After a urinary catheterization the client's fundus remains firm and four fingerbreadths above the umbilicus. What should the nurse do next?

A. Catheterize the client again
B. Palpate the client's fundus every 2 hours
C. Notify the client's practitioner immediately
D. Recheck the client's vital signs in 30 minutes

Answer 1

The nurse should immediately notify the client's practitioner due to the low blood pressure reading, which could be indicative of postpartum hemorrhage or other complications.

Step-by-step explanation:

When the fundus remains firm and four fingerbreadths above the umbilicus after urinary catheterization, and the bladder is known to be empty, the current data suggest that the bladder is no longer causing uterine displacement. Given that the client's blood pressure (BP) is significantly low at 86/40, which could indicate postpartum hemorrhage (PPH) or other forms of hypovolemia, the most immediate concern is the client's stability. The nurse should C. Notify the client's practitioner immediately to address the potential of PPH or other complications. While routinely palpating the fundus and checking vital signs are important aspects of postpartum care, the priority in this scenario is the client's low blood pressure and ensuring timely medical evaluation and intervention.