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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A client who had an uncomplicated vaginal birth at 38 weeks of gestation is currently 2 hours postpartum. A practical nurse is preparing to evaluate the client's uterine fundus and lochia. Arrange the following actions in the order the practical nurse should perform them to safely complete this evaluation.

  1. 1Instruct the client to void and explain the purpose of the evaluation.
  2. 2Assist the client into a flat, supine position with her knees slightly flexed.
  3. 3Put on clean gloves and pull down the perineal pad.
  4. 4Place one hand firmly just above the client's symphysis pubis.
  5. 5Cup the opposite hand and gently press downward to locate the top of the fundus.

Answer

The correct sequence begins with preparation (voiding and positioning), moves to infection control and observation (gloves and pad exposure), and concludes with the safe technique of palpation (supporting the lower segment before applying any downward pressure).
Safe fundal assessment requires a specific sequence: preparing the client by emptying the bladder and positioning to relax muscles, exposing the perineum to monitor lochia, and crucially, supporting the lower uterus before applying any downward palpation pressure.

Step-by-Step Solution

1
Instruct the client to void and explain the purpose of the evaluation.
The bladder is emptied and the client understands the process.
An overdistended bladder pushes the uterus up and out of the midline, causing inaccurate findings and potentially increasing bleeding.
2
Assist the client into a flat, supine position with her knees slightly flexed.
The client's abdominal muscles are relaxed.
Tight abdominal muscles make palpation difficult and uncomfortable; flexing the knees relieves this tension.
3
Put on clean gloves and pull down the perineal pad.
Standard precautions are established and the perineum is visible.
The nurse must observe the amount and character of lochia expelled while the fundus is being palpated.
4
Place one hand firmly just above the client's symphysis pubis.
The lower uterine segment is supported.
Failing to support the lower segment during fundal palpation can cause the uterus to invert, which is a medical emergency.
5
Cup the opposite hand and gently press downward to locate the top of the fundus.
The fundal height, firmness, and position are determined.
This action completes the data collection for postpartum uterine involution.

Key Concept

Postpartum Fundal Assessment Technique
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Topics

Ante/Intra/Postpartum and Newborn Care

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