medium · NCLEX-RN Health Promotion and Maintenance
The RN is assessing a postpartum client at 2 hours following delivery. The nurse finds the fundus is boggy and 2 cm above the umbilicus, and displaced to the right.
What is the first nursing action?
- Notify the provider of suspected retained placental fragments.
- Document 'fundus firm with massage' in the chart.
- Assist the client to void or catheterize if necessary.
- Increase the IV oxytocin infusion rate.
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