Question

When assessing a patient 24 hours after delivery and noting the fundus is 2 cm above the umbilicus, what action should the nurse prioritize?

A) Document the finding as normal postpartum uterine involution.

B) Massage the fundus to encourage proper descent.

C) Administer uterotonic medication to stimulate contractions.

D) Report the deviation from expected findings to the healthcare provider.

Answer 1

The nurse should prioritize administering uterotonic medication to stimulate contractions when assessing a patient 24 hours after delivery and noting the fundus is 2 cm above the umbilicus.

Step-by-step explanation:

When assessing a patient 24 hours after delivery and noting the fundus is 2 cm above the umbilicus, the nurse should prioritize administering uterotonic medication to stimulate contractions.

The fundus of the uterus is normally located just below the level of the umbilicus within the first 24 hours after delivery. A fundus that is 2 cm above the umbilicus indicates poor uterine involution and may be a sign of uterine atony, which can increase the risk of postpartum hemorrhage.

Administering uterotonic medication, such as oxytocin or misoprostol, can help stimulate contractions and promote proper involution of the uterus. This action can help prevent excessive bleeding and ensure optimal recovery for the patient.