A nurse is assessing a client 24 hours after delivery and notes the fundus is 2 cm above the umbilicus. Which action should the nurse take first?

• A. Administer oxytocin
• B. Ambulate the client to the bathroom
• C. Massage the fundus
• D. Place bed in Trendelenburg

Answer: (B)

A fundus that sits 2 cm above the umbilicus 24 hours after delivery suggests the uterus isn’t contracting properly and may be displaced by a full bladder. The priority is to relieve that distention so the uterus can contract and descend toward the midline, reducing the risk of postpartum hemorrhage.

Encouraging the client to void by ambulating to the bathroom directly addresses the most likely cause of the high fundus in this moment. After the patient voids, reassess the fundus. If it remains high or becomes boggy, proceed with fundal massage to stimulate contraction or other prescribed interventions. Trendelenburg positioning isn’t helpful here and isn’t used to treat a high, poorly contracting fundus.