A nurse assesses a client 12 hours post vaginal birth and finds a boggy uterus displaced above and to the right of the umbilicus. Which immediate nursing action is most appropriate?

• A. Assist the client in emptying her bladder
• B. Begin fundal massage
• C. Administer oxytocin
• D. Place the client in Trendelenburg

Answer: (A)

The situation reflects uterine atony after birth, with the uterus boggy and displaced upward and to the right. When the bladder is full, it pushes the uterus out of position and prevents it from contracting effectively. Emptying the bladder is the fastest way to relieve this displacement and allow the uterus to contract, helping it regain tone and descend toward its normal position.

After the bladder is emptied, reassess the uterus. If it remains boggy, perform fundal massage to stimulate contraction and, if needed, administer an oxytocic per protocol. Placing the patient in Trendelenburg isn’t appropriate here, as it doesn’t address the underlying issue and has potential risks.