Question

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment?

1. Ask the client to turn on her side.
2. Ask the client to urinate and empty her bladder.
3. Massage the fundus gently before determining the level of the fundus.
4. Ask the client to lie flat on her back, with her knees and legs flat and straight.

Answer 1

The nurse's initial action in a fundal assessment is to ask the postpartum client to urinate and empty her bladder, ensuring an accurate assessment of the uterus's position and tone.

Step-by-step explanation:

The initial nursing action when preparing to perform a fundal assessment on a postpartum client is to ask the client to urinate and empty her bladder. This step is essential because it allows for accurate assessment of the uterus's position and tone. If the bladder is full, it can push the uterus up and to the side, which may lead to a misassessment of uterine involution and could potentially mask postpartum hemorrhage.

Immediately after childbirth, the fundus of the uterus is palpable at or near the level of the belly button. When assessing the fundus, the nurse ensures that the mother is lying on her back with the knees slightly bent. The fundus is then palpated to ensure it is firm and to assess the uterine size, placement, and tone to determine whether it is contracting properly as part of the recovery process