A practical nurse is preparing to perform a routine fundal assessment on a client who is 12 hours postpartum following a spontaneous vaginal delivery at 39 weeks of gestation. In what order should the nurse perform the following actions? Arrange the steps in the correct clinical sequence.
- 1Instruct the client to void and completely empty their bladder.
- 2Assist the client into a supine position with their knees slightly flexed.
- 3Apply clean gloves and lower the perineal pad to expose the perineum.
- 4Place one hand firmly against the lower abdomen, just above the symphysis pubis.
- 5Palpate the top of the uterus (fundus) with the flat of the dominant hand.
Cevap
The correct sequence is: Instruct the client to void, assist the client into a supine position with knees flexed, apply clean gloves and lower the perineal pad, support the lower uterine segment just above the symphysis pubis, and finally palpate the top of the uterus.
The correct sequence ensures patient safety, accurate data collection, and proper infection control. The bladder must be completely empty first to prevent uterine displacement. The client is then appropriately positioned to relax abdominal muscles. Gloves are donned and the pad is lowered to maintain standard precautions and allow observation of lochia. Critically, the lower uterine segment must be firmly supported before palpating the top of the fundus to prevent uterine inversion.
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Postpartum Fundal Assessment Procedure