A nurse is assessing a postpartum client 12 hours after vaginal delivery. Which assessment finding requires the nurse's immediate attention?

Key Clinical Alert: A fundus palpated 3 fingerbreadths above the umbilicus and deviated to the right is a sentinel sign of a distended bladder. This mechanical displacement prevents the uterus from contracting firmly, directly precipitating uterine atony and placing the patient at high risk for early postpartum hemorrhage.

Immediate Nursing Actions:

• Assist with Bladder Emptying: The priority intervention is to assist the patient to void. Implement non-invasive measures first: provide privacy, run water, or use perineal warm water sprays. If unable to void within 15-30 minutes, perform a straight catheterization as ordered to relieve the distention.
• Reassess Fundus Immediately: After the bladder is emptied, immediately re-palpate the fundus. It should be firm, midline, and at or below the level of the umbilicus. If the fundus remains boggy or displaced, begin fundal massage and escalate care.
• Monitor for Hemorrhage: Concurrently assess lochia amount, vital signs, and signs of hypovolemia (tachycardia, hypotension, pallor). Quantify blood loss by weighing pads and noting saturation.

Pathophysiology and Rationale: A full bladder mechanically pushes the uterus superiorly and laterally. The over-distended uterine muscle cannot sustain a tetanic contraction, leaving the spiral arteries at the placental site open. This is the mechanism for atonic bleeding, the leading cause of PPH within the first 24 hours.

Ongoing Management: If fundal massage and bladder emptying do not restore tone, initiate the facility's PPH protocol. This includes administering uterotonic medications (e.g., oxytocin), establishing IV access, and preparing for potential bimanual compression or surgical intervention.