A nurse assesses a client 1 hour after vaginal delivery and finds the uterine fundus is boggy, displaced to the right of midline, and the client has soaked two perineal pads. Which action should the nurse perform first?
- A.Administer oxytocin IV as ordered
- B.Assist the client to urinate or insert a urinary catheter
- C.Perform firm fundal massage until the uterus is firm
- D.Notify the provider immediately
Show answer & rationale
Correct answer
B. Assist the client to urinate or insert a urinary catheter
Rationale
B is correct: A boggy uterus displaced to the right of midline indicates a distended bladder preventing uterine contraction. The nurse must first relieve the bladder (by having the client void or catheterizing) before fundal massage, because a full bladder is the cause. Massaging an atonic uterus that has a full bladder will not be effective until the bladder is emptied. A is incorrect: Oxytocin may ultimately be needed, but addressing the cause (bladder distension) takes priority. C is incorrect: Fundal massage before emptying the bladder will be ineffective because the displaced bladder is preventing the uterus from contracting into midline. D is incorrect: Provider notification is important but should follow the immediate nursing intervention of bladder emptying.
Key concepts