A nurse is assessing a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

Choice A rationale
Massaging the fundus is not necessary in this case. The fundus is firm, which indicates that the uterus is well contracted and there is no risk of postpartum hemorrhage. Massaging a well- contracted uterus can lead to uterine involution or even inversion.

Choice B rationale
Having the patient urinate is the correct action. A displaced fundus can be a sign of a full bladder. The bladder can push the uterus to the side and prevent it from contracting properly. By emptying the bladder, the uterus can return to its proper position and continue to contract to prevent bleeding.
Choice C rationale
Inserting a urinary catheter is not the first step. The nurse should first ask the patient to urinate. If the patient is unable to urinate, then a catheter may be necessary.
Choice D rationale
Administering an analgesic is not related to the position of the fundus. Pain management is important in postpartum care, but it is not the reason for a displaced fundus.

Choice A rationale
A displaced fundus from the midline in a postpartum client can indicate a full bladder, which can interfere with uterine contraction and lead to excessive bleeding. This is a serious

condition that requires immediate attention to prevent further complications such as postpartum hemorrhage.
Choice B rationale
A fundal height below the umbilicus is a normal finding in a postpartum client. The uterus normally decreases in size after delivery, and the fundus is typically located at or below the level of the umbilicus within 24 hours postpartum.
Choice C rationale
Increased urine output is a normal physiological response after delivery. During pregnancy, there is an increase in blood volume that leads to increased fluid in the body. After delivery, the body eliminates this extra fluid through increased urine output.
Choice D rationale
A decreased urge to void can be a normal finding in the immediate postpartum period due to decreased bladder sensitivity from the trauma of childbirth or epidural anesthesia. However, it’s important for the nurse to monitor this because urinary retention can lead to bladder distention and uterine atony, increasing the risk of postpartum hemorrhage.