A postpartum client who delivered vaginally 8 hours ago has a fundus 2 fingerbreadths above the umbilicus and displaced to the left with heavy lochia rubra. Which action should the nurse take first?

• A. Apply a perineal ice pack
• B. Assist the client to the toilet
• C. Call the physician
• D. Begin IV fluids

Answer: (B)

The situation tests how to interpret a postpartum fundus that is high, displaced, and accompanied by heavy lochia. A fundus that sits above the umbilicus and is off to the side usually means the bladder is distended. A full bladder pushes the uterus up and to the side, making it appear displaced and sometimes boggy because the uterus isn’t contracting efficiently.

The priority is to relieve the bladder distention by helping the client to void. Encouraging the patient to go to the bathroom and empty the bladder allows the uterus to settle back into a midline position and resume involution, which often restores a firm, midline fundus. After voiding, reassess the fundus: it should be firm and at or below the umbilicus. If the fundus remains high or boggy after voiding, then you would proceed with further interventions such as fundal massage and evaluation for hemorrhage.

The other actions don’t address the immediate cause of the displacement or are not the first step in this scenario.