On completing fundal palpation, the nurse notes that the fundus is located to the right side of the abdomen. Which action is appropriate?

Choice A rationale A fundus located to the right side of the abdomen (a lateral deviation) and potentially higher than expected is the classic sign of a distended bladder. A full bladder physically displaces the uterus from its normal midline, contracted position, which also hinders effective uterine muscle contraction (atony), increasing the risk of postpartum hemorrhage. The first appropriate, least invasive action is to ask the client to empty her bladder. Choice B rationale Straight-catheterizing the client immediately is an invasive procedure and is generally reserved for situations where the client is unable to void voluntarily after other measures, like position changes or running water, have been attempted. It is not the initial, least-risk intervention for a displaced fundus, as the client may be able to void naturally. Choice C rationale Calling the client's primary health care provider for direction is unnecessary as the nurse's assessment findings point clearly to a common, manageable postpartum issue: bladder distension causing uterine displacement. The appropriate, evidence-based nursing protocol is to first attempt to have the client void spontaneously to correct the displacement. Choice D rationale Straight-catheterizing the client for half of her urine volume is not a standard procedure. If catheterization becomes necessary because the client cannot void, the goal is to fully empty the bladder to relieve the pressure and allow the uterus to contract properly. Only complete bladder emptying will effectively resolve the uterine displacement and reduce hemorrhage risk.