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Which of the following initial nursing actions has to be taken before performing fundal assessment on a post-partum client?
Question

Which of the following initial nursing actions has to be taken before performing fundal assessment on a post-partum client?

A.

Ask the mother to turn to her side.

B.

Ask the mother to lie flat on her back with the knees and legs flat and straight.

C.

Ask the mother to empty her bladder.

D.

Massage the fundus gently before determining the level of the fundus.

Correct option is C

Before assessing the fundus in a post-partum mother, the nurse should first ask the mother to empty her bladder. A full bladder can push the uterus upward and to the side, giving a false impression of uterine size or tone. Emptying the bladder ensures accurate assessment of the fundal height and position, which is critical in monitoring for postpartum hemorrhage or uterine atony.
Explanation of options: (a) Ask the mother to turn to her side – This position is not ideal for fundal assessment; supine positioning is required to palpate the uterus effectively. (b) Ask the mother to lie flat on her back with the knees and legs flat and straight – While positioning is important, it comes after ensuring the bladder is emptied to avoid displacement of the uterus. (c) Ask the mother to empty her bladder – This is the correct answer. A distended bladder can displace the uterus and interfere with an accurate assessment. (d) Massage the fundus gently before determining the level of the fundus – Fundal massage is done after the assessment if the uterus is found to be boggy, not before determining its level.

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