1. Two hours after delivery the nurse assesses the client and documents that the

fundus is soft, boggy, above the level of the umbilicus, and displaced to the

right side. The nurse encourages the client to void. Which is the rationale for

this nursing action?

Correct: Bladder distention can lead to postpartum hemorrhage. A full

bladder displaces the uterus causing it not to contract properly. Emptying

the bladder allows the uterus to contract more firmly.

 Incorrect: A distended bladder rises out of the abdomen, causing the uterus to

be displaced and increasing the risk of hemorrhage. It does not affect the

perineum.

 Incorrect: Bladder distention can lead to urinary stasis and infection. This,

however, does not relate to the soft, boggy uterus or the potential for

hemorrhage.