Question

A 41-year-old multipara client had a spontaneous vaginal delivery of an 8-lb (3,629-g) baby 3 hours ago. The nurse collects the following data: "Fundus firm, three fingerbreadths above the umbilicus and deviated to the right. Perineal pad saturated after 20 minutes." Which nursing intervention by the licensed practical nurse (LPN) is best?

a) Massage the fundus to the midline and reassess for firmness.
b) Administer an analgesic to relieve perineal discomfort.
c) Instruct the client to perform Kegel exercises regularly.
d) Document the findings as normal postpartum changes.

Answer 1

The nurse should massge the fundus to the midline and reassess for firmness.

Step-by-step explanation:

The nurse should massage the fundus to the midline and reassess for firmness. The fundus being deviated to the right indicates a possible full bladder, which can prevent proper uterine involution and increase the risk of postpartum hemorrhage. Massage will help stimulate uterine contractions and promote involution. Assessing for firmness after massage helps ensure that involution is occurring.