Question

When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to: A. Check the client for bladder distention B. Assess the blood pressure for hypotension C. Determine whether an oxytoxic drug was given D. Check for the expulsion of small clots

Short answer

Answer: Check the client for bladder distention.

Step-by-step solution

Understanding the question

We need to determine the appropriate nursing action when the fundus is firm, at the level of the umbilicus, and displaced to the right on the first postpartum day.

Evaluating each answer choice

A) Check the client for bladder distention: When the fundus is displaced to the right, it is often a sign that the bladder is full and distended, which can prevent the uterus from contracting properly. B) Assess the blood pressure for hypotension: Hypotension is not directly related to the position and firmness of the fundus. While it is important to regularly monitor blood pressure in postpartum patients, it is not the priority in this specific situation. C) Determine whether an oxytoxic drug was given: Oxytoxic drugs are used to stimulate uterine contractions and control bleeding after delivery. Although it is relevant to know if the patient received these medications, it doesn't directly address the issue of the displaced fundus. D) Check for the expulsion of small clots: The expulsion of small clots is normal in the postpartum period. However, the presence or absence of clots does not address the issue of the displaced fundus.

Choosing the correct answer

Based on the evaluation of the options, the correct answer is A) Check the client for bladder distention. This is the appropriate action as a full bladder can cause the fundus to be displaced, and emptying the bladder can help the uterus to contract properly and return to its normal position as it undergoes involution.