A nurse is caring for a client who is 14 hours postpartum.



The nurse notes that the client’s breasts are soft, the fundus is firm and slightly deviated to the right, and the client’s
pulse rate is 88/min with a respiratory rate of 18/min.
Which of the following actions should the nurse take?

Choice A rationale:

Placing the mother in Trendelenburg's position would not correct the uterine displacement. Trendelenburg's position involves

lowering the head of the bed and raising the feet, which can actually worsen uterine displacement by increasing pressure on

the uterus from the abdominal organs.

It is not indicated for uterine displacement and could potentially have adverse effects on the patient's hemodynamic status

and respiratory function.

Choice C rationale:

Notifying the physician is important, but it is not the first action the nurse should take.

The nurse should assess the patient and attempt to correct the displacement before notifying the physician.

Choice D rationale:

Recording the findings is important for documentation, but it is not an intervention that will correct the uterine displacement.

Choice B rationale:

Massaging the fundus is the correct action to take when a postpartum uterus is displaced.

The fundus is the top of the uterus, and massaging it can help to stimulate the uterine muscles to contract and return to their

normal position.

This is often effective in correcting mild to moderate uterine displacements.

Here are the steps involved in massaging the fundus:

Locate the fundus: The nurse should first locate the fundus by palpating the abdomen just below the umbilicus.

Apply gentle pressure: Once the fundus is located, the nurse should apply gentle pressure with the fingertips in a circular

motion.

Continue massaging: The massage should be continued for several minutes, or until the uterus is felt to be firm and in the

midline position.

Additional notes:

If the uterine displacement is severe, or if the patient is experiencing pain or bleeding, the nurse should notify the physician

immediately.

Other interventions that may be used to correct uterine displacement include:

Assisting the patient to empty her bladder

Straight catheterization

Administration of oxytocin to stimulate uterine contractions

Choice A rationale:

Assisting the client to ambulate is not the immediate action required in this scenario. The nurse has found a small amount of

lochia rubra on the client’s perineal pad, and the fundus is midline and firm at the umbilicus. These are normal findings for a

client who is 4 hours postpartum. However, the nurse should ensure that there is no excessive bleeding, which could be a sign

of postpartum hemorrhage.

Choice B rationale:

Performing a fundal massage is not necessary in this case. Fundal massage is usually performed when the uterus is boggy or

soft, which could indicate uterine atony, a leading cause of postpartum hemorrhage. In this scenario, the fundus is firm and at

the level of the umbilicus, which is a normal finding 4 hours postpartum.

Choice C rationale:

Increasing the rate of IV fluids is not the immediate action required in this scenario. IV fluids are usually increased to expand

intravascular volume in cases of postpartum hemorrhage. In this case, the nurse has found a small amount of lochia rubra on

the client’s perineal pad, which is a normal finding 4 hours postpartum.

Choice D rationale:

Checking for blood under the client’s buttocks is the correct action for the nurse to take in this scenario. This is to ensure that

there is no excessive bleeding, which could be hidden under the client’s buttocks. Excessive bleeding could be a sign of

postpartum hemorrhage, a potentially life-threatening complication.