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    Ati maternal newborn 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. Decreased urge to void: A decreased urge to void is common in the early postpartum period due to bladder edema or trauma from delivery. While it requires monitoring and potential intervention, it is not an immediate threat to the client’s safety. B. Increased urine output: Increased diuresis is expected postpartum as the body eliminates excess fluid accumulated during pregnancy. It usually occurs within the first 24 to 48 hours and is a normal physiological response. C. Displaced fundus from the midline: A displaced fundus, especially to the right, usually indicates bladder distention, which can interfere with uterine involution and increase the risk of postpartum hemorrhage. Immediate intervention is required to encourage voiding and prevent excessive bleeding. D. Fundal height below the umbilicus: A fundus located 1 cm below the umbilicus is expected on postpartum day one. It reflects appropriate uterine involution and does not require urgent action.

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