On the first postpartum day, the fundus is firm and located 1 fingerbreadth above and to the right of the umbilicus, with moderate lochia rubra and small clots, temperature 99.2°F, and pulse 52/min. Which action should the nurse take?

• A. Check respiratory status.
• B. Administer broad-spectrum antibiotics.
• C. Reassess vital signs in 6 hours.
• D. Ask the client when she last voided.

Answer: (A)

Fundal height that is higher than expected and displaced to one side often points to bladder distension rather than a problem with the uterus itself. A full bladder pushes the uterus upward and to the side, even if the uterus is firm, so the priority is to assess and relieve the distension.

Asking the client when she last voided helps determine if a distended bladder is present and guides the next step—encouraging or assisting to void (or catheterize if needed). Once the bladder is emptied, the fundus should settle lower and stay midline, which supports proper involution and reduces risk of hemorrhage.

The other options aren’t addressing the likely issue here: checking respiratory status isn’t indicated by the current signs, antibiotics aren’t warranted without infection, and waiting several hours to reassess would delay necessary intervention to relieve bladder distention.