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    Ati nur 114 paediatrics proctored exam

    A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

    Explanation & Rationale

    A. Displaced fundus from the midline: A fundus displaced from the midline, often due to a full bladder, can indicate uterine atony and increases the risk of postpartum hemorrhage. Immediate intervention is required to assess bladder status, assist with voiding, and ensure proper uterine contraction. B. Fundal height below the umbilicus: On the first postpartum day, it is normal for the fundus to be at or just below the level of the umbilicus. This finding reflects expected involution of the uterus and does not typically require urgent action. C. Increased urine output: Increased diuresis is common in the first 24 hours postpartum as the body eliminates excess fluid accumulated during pregnancy. This is a normal physiologic process and does not require immediate intervention. D. Decreased urge to void: A reduced sensation to void may occur due to perineal trauma, anesthesia, or decreased bladder tone. While it should be monitored and managed to prevent retention, it is not immediately life-threatening compared to a displaced fundus.

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