CRNE Exam Prep

Category - Changes in Health

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A nurse is assessing a client who gave birth twelve 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?

Place the client on her left side
Massage the fundus
Ask the client to void
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 be re-checked. The other options are not appropriate.

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