A nurse is assessing a client who is 1 week postpartum. Which of the following locations should the nurse palpate to assess the client's fundus? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A
B
C
The Correct Answer is {"xRanges":[299.765625,329.765625],"yRanges":[366.609375,396.609375]}
Choice A rationale: This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation).
Choice B rationale: This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation). It then decreases steadily at approximately 1 cm every 24 hours.
Choice C rationale: One-week post-partum, the fundal height should be about 7 cm below the umbilicus (belly button). This means that the uterus is still larger than normal, but it is contracting and healing. The fundal height may vary depending on factors such as the size and position of the baby, the amount of amniotic fluid, and the mother's body type.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Awakening the client frequently throughout the day is not necessary and can disturb their rest and comfort.
Choice B rationale:
Using an electric blanket can increase the risk of burns or overheating in a client who is approaching death and may have reduced ability to regulate body temperature.
Choice C rationale:
Positioning the client on their side with the head of the bed elevated can facilitate drainage of respiratory secretions, maintain airway patency, and provide comfort.
Choice D rationale:
Encouraging the client to eat soft foods intermittently may not be relevant, as the client's ability to eat and swallow may be limited in the end stages of life.
Correct Answer is B
Explanation
Choice A rationale:
Using a disposable adhesive probe when measuring the client's SaO2 is not an intervention that can reduce the exposure of the client to latex, because adhesive probes may contain latex and cause skin reactions. A better option would be to use a non-adhesive probe or a probe cover that is latex-free.
Choice B rationale:
Rationale: Latex sensitivity or allergy can lead to adverse reactions when exposed to latex- containing products, such as blood pressure cuffs. Wrapping the blood pressure cuff in a stockinette helps minimize direct contact between the cuff and the client's skin.
Choice C rationale:
Silicone products are usually considered safe for individuals with latex sensitivity because silicone is a different material. Silicone products are generally safe for clients who are sensitive to latex, unless they have a separate allergy to silicone.
Choice D rationale:
Cleaning vial stoppers for 15 seconds before using them to withdraw-medications for the client is not an intervention that can reduce the exposure of the client to latex, because vial stoppers may be made of latex or rubber and cleaning them does not remove the allergen. A better option would be to use vials that have latex-free stoppers or to avoid puncturing the stoppers with needles.
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