A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes breasts soft, fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?
A.
Encourage the client to nurse more frequently so her milk will come in.
B.
Increase IV fluids.
C.
Ask the client to empty her bladder.
D.
Report the client’s temperature elevation.
The Correct Answer and Explanation is:
The correct answer is C. Ask the client to empty her bladder.
Explanation:
In the context of postpartum care, the assessment findings indicate that the client is 14 hours postpartum with a few notable observations: her breasts are soft (which may indicate that the milk has not fully come in yet), her fundus is firm but slightly deviated to the right, and she has moderate lochia rubra. The temperature is slightly elevated at 37.7° C (100° F), with pulse and respiratory rates within normal limits.
One critical factor to consider in this scenario is the deviation of the fundus. A firm fundus that is slightly deviated to the right often indicates that the bladder may be distended. This distention can push the uterus out of its midline position, which can impede uterine involution and contribute to increased lochia and the potential for postpartum hemorrhage. Encouraging the client to empty her bladder can help correct this deviation, allowing the uterus to contract more effectively and reduce the risk of complications.
While encouraging breastfeeding (option A) is generally beneficial for stimulating milk production, it does not directly address the potential issue of a distended bladder. Increasing IV fluids (option B) is not necessary unless the client shows signs of dehydration or has specific orders for fluid management. Reporting the temperature elevation (option D) may be appropriate if it were significantly higher or accompanied by other signs of infection, but a temperature of 37.7° C is often acceptable in the early postpartum period.
In summary, the most immediate and relevant nursing action is to assist the client in emptying her bladder, which can help in repositioning the fundus, promoting uterine involution, and reducing lochia flow.