A nurse is assessing a client who gave birth 12 hours ago. On assessment, the nurse notes that the client’s fundus is above the umbilicus to the right. Which of the following is the nurse’s initial action?
  1. Place the client on her left side
  2. Massage the fundus
  3. Ask the client to void
  4. Notify the physician
Explanation
Answer: C - A fundus above the umbilicus and to the right suggests a full bladder. The nurse should ask the client to void and then recheck the client. The other options are not appropriate.
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