A nurse is collecting data from a client who is 1 day postpartum.Which of the following findings requires immediate intervention by the nurse?
Decreased urge to void.
Displaced fundus from the midline.
Fundal height below the umbilicus.
Increased urine output.
The Correct Answer is B
Choice A rationale
A decreased urge to void is a common postpartum finding due to the effects of anesthesia and the trauma of childbirth. It does not require immediate intervention unless it leads to bladder distention.
Choice B rationale
A displaced fundus from the midline, especially if it is accompanied by a boggy uterus, indicates uterine atony, which can lead to postpartum hemorrhage. Immediate intervention is required to prevent severe blood loss.
Choice C rationale
A fundal height below the umbilicus is an expected finding 1 day postpartum as the uterus begins to involute. This does not require immediate intervention.
Choice D rationale
Increased urine output is common in the postpartum period as the body eliminates excess fluid accumulated during pregnancy. This is not a cause for immediate concern.
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Correct Answer is C
Explanation
Choice A rationale
Checking blood pressure is important but not the first action to control bleeding.
Choice B rationale
Observing the client is necessary but not the immediate action to control bleeding.
Choice C rationale
Massaging the fundus helps the uterus contract and can reduce bleeding, which is crucial in managing postpartum hemorrhage.
Choice D rationale
Administering oxytocin is important but should follow fundal massage to ensure the uterus is contracting.
Correct Answer is A
Explanation
Choice A rationale
At 1 cm above the umbilicus is the expected position of the uterine fundus 12 hours postpartum. After delivery, the fundus is typically at the level of the umbilicus and then descends approximately 1 cm per day. At 12 hours postpartum, it is normal for the fundus to be slightly above the umbilicus.
Choice B rationale
One fingerbreadth above the symphysis pubis is not the expected position of the fundus 12 hours postpartum. This position is more typical several days postpartum as the uterus continues to involute and return to its pre-pregnancy size.
Choice C rationale
To the right of the umbilicus is not a normal finding and may indicate a full bladder, which can displace the uterus. The nurse should assist the client to void and then reassess the fundal position.
Choice D rationale
Three fingerbreadths above the umbilicus is not expected 12 hours postpartum. This position may indicate uterine atony or subinvolution, which requires further assessment and intervention.