A practical nurse is preparing to assess the uterine involution of a multiparous client who is 12 hours postpartum. In which order should the nurse perform the following actions to safely and accurately assess the fundus? (Arrange the steps in the correct sequence from first to last.)
- 1Instruct the client to completely empty her bladder.
- 2Assist the client into a supine position with her knees slightly flexed.
- 3Don clean gloves and lower the perineal pad to observe the lochia.
- 4Place one hand just above the symphysis pubis to stabilize the lower uterine segment.
- 5Use the flat of the opposite hand to firmly palpate the abdomen and locate the fundus.
Answer
The correct sequence is: Instruct the client to empty her bladder, assist her into a supine position with flexed knees, don gloves and observe the perineal pad, stabilize the lower uterine segment, and finally palpate the fundus.
A safe and accurate fundal assessment must follow a strict, logical sequence. First, the bladder must be empty to avoid uterine displacement. Second, the client must be positioned correctly (supine with knees flexed) to relax the abdomen. Third, the nurse applies gloves and checks current lochia as a baseline. Finally, when performing the physical palpation, the nurse must always stabilize the lower uterine segment with one hand before pressing on the fundus with the other hand to prevent uterine inversion.
Step-by-Step Solution
Key Concept
Postpartum Fundal Assessment Technique