A nurse is collecting data from a client who gave birth 12 hours ago. The nurse notes the fundus is deviated to the right, boggy, and 2 cm above the umbilicus. Which of the following actions should the nurse take first?

Choice A rationale A fundus that is deviated to the right, boggy, and 2 cm above the umbilicus suggests a distended bladder is displacing the uterus, preventing it from contracting effectively. A full bladder inhibits uterine involution by impeding the muscle fibers from compressing blood vessels, leading to uterine atony and increasing the risk of postpartum hemorrhage. Normal bladder capacity is 300-500 mL. Choice B rationale Obtaining a stat hemoglobin level is not the immediate priority. While a boggy uterus can indicate blood loss, the primary issue here is likely bladder distension causing uterine atony. Addressing the cause of the uterine displacement (bladder distension) takes precedence over assessing the degree of blood loss, which would be a secondary consequence. A normal hemoglobin for a woman is typically 12.0 to 15.5 grams per deciliter. Choice C rationale Administering methylergometrine is not the first action. Methylergometrine is a uterotonic agent used to promote uterine contractions and prevent postpartum hemorrhage. However, if the uterus is displaced by a full bladder, the medication's effectiveness will be significantly reduced until the bladder is emptied. Treating the underlying cause is crucial before administering uterotonics. Choice D rationale Inserting an indwelling urinary catheter is a more invasive intervention than assisting the client to void. While a catheter might be necessary if the client cannot void independently, the initial and least invasive action should always be to encourage spontaneous urination. Catheterization carries risks of urinary tract infection and discomfort, so it's not the first-line intervention.