MEDizzy - A nurse is assisting in the delivery of a term newborn.

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Care of Childbearing Families

A nurse is assisting in the delivery of a term newborn. Immediately after delivery of the placenta, the nurse palpates the uterine fundus and finds that it is firm and located halfway between the client’s umbilicus and symphysis pubis. Which action should the nurse take based on the assessment findings?

ExplanationImmediately after birth, the uterus should contract and the fundus should be located one-half to two-thirds of the way between the symphysis pubis and umbilicus. Thus the only intervention required is to document the assessment finding. There is no indication that the bladder is full. A full bladder will cause uterine displacement to either side of the abdomen. Uterine massage is indicated only if the uterus does not feel firm and contracted. Since the uterus is firm, there is no reason to suspect that increased vaginal discharge would occur.