A nurse is assessing a client who is 8 hour postpartum. Where should the nurse expect to find the fundus?
at the umbilicus
At a non-palpable depth
just above the symphysis pubis
just below the umbilicus
The Correct Answer is D
A) At the umbilicus:
After delivery, the fundus is typically located at or just below the umbilicus in the immediate postpartum period, but it will gradually descend over the next few days. By 8 hours postpartum, the fundus is often slightly below the umbilicus, not directly at the umbilicus. The fundus will continue to shrink in size and move downward toward the pelvic region as the uterus contracts and involutes.
B) At a non-palpable depth:
A fundus that is non-palpable is generally expected later in the postpartum period, typically by 10-14 days after delivery, as the uterus contracts and returns to its pre-pregnancy size. At 8 hours postpartum, the fundus is still palpable, generally just below the umbilicus, and should be evaluated for firmness and position.
C) Just above the symphysis pubis:
The fundus is usually higher than the symphysis pubis at 8 hours postpartum, as it is still in the process of descending from the higher position it occupied during pregnancy. It would be expected to be just below the umbilicus or about 1 to 2 finger widths below it. By the second or third day postpartum, the fundus begins to move lower toward the symphysis pubis as it continues to involute.
D) Just below the umbilicus:
Eight hours after delivery, the nurse should expect to palpate the fundus just below the umbilicus. This is a typical finding as the uterus begins to contract and shrink after the delivery of the placenta. The fundus will descend about 1-2 cm per day postpartum, so by 8 hours, it is usually just slightly below the level of the umbilicus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","I","K"]
Explanation
The newborn's assessment findings that require follow-up:
Temperature 35.7°C (96.3°F) at 2200:
Hypothermia in newborns can lead to cold stress, which increases the risk of respiratory distress and hypoglycemia. The newborn’s temperature should be closely monitored, and warming measures should be initiated to prevent further complications.
Respiratory rate 68/min at 2200:
A respiratory rate above 60 breaths per minute in a newborn is considered tachypnea and can indicate respiratory distress or underlying conditions such as infection. The newborn should be further evaluated to determine the cause of the tachypnea and to ensure proper oxygenation.
Sternal retractions at 2200:
Sternal retractions suggest that the newborn is experiencing increased work of breathing, which is a key sign of respiratory distress. This requires immediate evaluation to assess the severity and identify potential causes, such as respiratory infections or inadequate ventilation.
Coarse rhonchi in bilateral lung fields at 2200:
The presence of coarse rhonchi indicates abnormal breath sounds, often related to fluid retention or infection in the lungs. This finding requires further assessment and possibly interventions to clear the airway and support respiratory function.
Correct Answer is D
Explanation
A) Palmer grasp reflex:
The palmer grasp reflex is a primitive reflex in which a newborn will grasp an object placed in their hand. While this reflex is present at birth, it typically disappears by 5-6 months of age, not by 3-4 months. The Moro reflex, which is more related to startle and sudden movements, is the correct answer in this case.
B) Babinski reflex:
The Babinski reflex, in which the toes fan out when the sole of the foot is stroked, is present at birth but typically disappears by 12 months. This reflex is an indicator of neurological development, and its presence beyond the first year could suggest neurological concerns, but it is not the reflex in question here.
C) Rooting reflex:
The rooting reflex occurs when the newborn turns their head and opens their mouth in response to cheek stimulation, typically to find the nipple for breastfeeding. This reflex is present at birth and usually disappears by 3-4 months, which is similar to the timing mentioned in the question.
D) Moro reflex:
The Moro reflex is a startle reflex in which the infant spreads their arms and then pulls them back in when they feel a sudden loss of support or a loud noise. This reflex is present at birth and typically disappears by 3-4 months of age. It is considered a classic primitive reflex that fades as the infant's nervous system matures.
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