A practical nurse is collecting data on the uterine involution of a client who experienced a spontaneous vaginal birth 14 hours ago. In which order should the nurse perform the steps of the fundal assessment? Arrange the actions from first to last.
- 1Instruct the client to void and empty her bladder completely.
- 2Assist the client into a supine position with her knees slightly flexed.
- 3Don clean gloves and pull down the perineal pad to observe the lochia.
- 4Place one hand just above the symphysis pubis to stabilize the lower uterine segment.
- 5Palpate the abdomen with the flat part of the opposite hand to locate the fundus.
Answer
The correct sequence requires preparing the client by emptying the bladder and optimizing positioning, then applying standard precautions to check baseline bleeding, and finally using a two-handed technique starting with lower uterine support before pressing on the fundus.
A systematic approach to fundal assessment ensures accurate data collection and client safety. An empty bladder prevents upward and lateral displacement of the uterus. Positioning with flexed knees relaxes the abdominal muscles for easier palpation. Donning gloves and checking lochia first provides a baseline assessment of bleeding before uterine manipulation. Finally, supporting the lower uterine segment is a mandatory clinical safety measure before fundal palpation to prevent uterine inversion.
Step-by-Step Solution
Key Concept
Postpartum Uterine Fundal Assessment Sequence