A nurse is assessing a postpartum client who delivered vaginally 2 days ago and notes that her fundus is boggy and displaced to the right side of her abdomen.

Which of the following actions should the nurse take first?

The correct answer is choice E) Temperature greater than 38°C for more than 48 hours.This is because a fever higher than 38°C that lasts for more than two days can indicate a postpartum infection, which is a potentially serious complication that requires immediate medical attention.A postpartum infection can affect various parts of the body, such as the uterus, the breast, or the urinary tract.

Choice A) Lochia with clots is wrong because lochia is the normal vaginal discharge that occurs after childbirth and may contain some blood clots.However, if the lochia is foul-smelling, excessive, or bright red, it may be a sign of infection.

Choice B) Fundus firmness is wrong because a firm fundus (the top of the uterus) indicates that the uterus is contracting well and preventing excessive bleeding.A soft or boggy fundus can be a sign of infection or hemorrhage.

Choice C) Abdominal distension is wrong because some abdominal swelling is normal after delivery and may take several weeks to subside.However, if the abdomen is very tender, painful, or hard, it may be a sign of infection or other complications.

Choice D) Breast tenderness is wrong because some

The correct answer is choice D. Massage her fundus.

This is because a boggy and displaced fundus indicates uterine atony, which is the failure of the uterus to contract sufficiently after delivery.

This can lead to excessive bleeding and postpartum hemorrhage.Massaging the fundus can help stimulate uterine contractions and reduce blood loss.

Choice A is wrong because administering oxytocin is not the first action the nurse should take.Oxytocin is a medication that can also help the uterus contract, but it should be given after massaging the fundus and assessing the bleeding.

Choice B is wrong because assisting with ambulation is not appropriate for a client with a boggy and displaced fundus.Ambulation can increase bleeding and cause orthostatic hypotension due to blood loss.

Choice C is wrong because encouraging frequent voiding is not the first action the nurse should take.

A full bladder can displace the uterus and prevent effective contractions, so voiding can help the uterus return to its normal position.However, this should be done after massaging the fundus and assessing the bleeding.