A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?
Explanation & Rationale
Rationale: A. Encourage the client to move to the left lateral position is incorrect because while positioning can help comfort and circulation, it does not correct uterine displacement or a boggy fundus. The primary concern is uterine atony due to bladder distention, not positioning. B. Encourage the client to perform Kegel exercises is incorrect because Kegel exercises strengthen pelvic floor muscles but do not address uterine atony or displacement. They are appropriate for long-term pelvic floor recovery, not acute fundal management. C. Assist the client to the bathroom to void is correct because a boggy and displaced fundus often indicates a full bladder, which prevents the uterus from contracting effectively. Urinary retention can lead to uterine atony and postpartum hemorrhage. Having the client void or using a catheter if necessary allows the fundus to return to midline and become firm, reducing bleeding risk. D. Ask the client to rate her pain is incorrect because while assessing pain is part of routine postpartum care, it does not address the immediate priority of correcting fundal atony and displacement, which can lead to postpartum hemorrhage if left uncorrected.