A nurse is caring for a client who experienced a vaginal delivery 12 hours ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?
2 cm above the umbilicus
At the level of the umbilicus
One fingerbreadth above the symphysis pubis
To the right of the umbilicus
The Correct Answer is B
The correct answer is choice B. At the level of the umbilicus.
Choice A rationale:
The fundus is typically not found 2 cm above the umbilicus 12 hours postpartum. This position is more common immediately after delivery or in cases of uterine atony or retained placental fragments.
Choice B rationale:
At 12 hours postpartum, the uterine fundus is expected to be at the level of the umbilicus. This indicates normal involution of the uterus, where it contracts and shrinks back to its pre-pregnancy size.
Choice C rationale:
One fingerbreadth above the symphysis pubis is not a typical position for the fundus 12 hours after delivery. This position is more likely several days postpartum as the uterus continues to involute.
Choice D rationale:
The fundus being to the right of the umbilicus may indicate a full bladder, which can push the uterus to one side. This is not a normal finding 12 hours postpartum and would require intervention to empty the bladder.
: https://bchsfoutreach.ucsf.edu/sites/bchsfoutreach.ucsf.edu/files/handouts/Washington%20Hospital%20Postpartum%204-2018.pdf : https://nursekey.com/fundal-palpation-postpartum/
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Suctioning excess mucus with a bulb syringe is a standard procedure to clear the airways of a newborn and facilitate breathing. While it is an important aspect of initial newborn care, it does not directly prevent jaundice. Jaundice is caused by high levels of bilirubin in the blood, and suctioning mucus does not influence bilirubin levels.
Choice B reason:
Initiating early feeding, whether breastfeeding or formula feeding, is recommended to prevent jaundice. Early feeding helps stimulate bowel movements, which aids in the excretion of bilirubin through the stool. Breastfed babies should be fed eight to twelve times a day during their first week of life, and formula-fed babies should receive one to two ounces (30 to 60 milliliters) of formula every two to three hours during their first week. This frequent feeding schedule helps ensure that bilirubin does not build up to high levels in the newborn's system.
Choice C reason:
Preparing for an exchange blood transfusion is a treatment measure for severe jaundice, not a preventive action. This procedure is only considered when bilirubin levels are dangerously high and could potentially cause brain damage. It is not a standard preventive measure for jaundice in newborns.
Choice D reason:
Beginning phototherapy is a treatment method for newborns who have already developed jaundice, not a preventive measure. Phototherapy uses light to break down bilirubin in the skin, making it easier for the baby's body to eliminate it. While effective in treating jaundice, it is not used as a preventive action.
Question 65
Correct Answer is C
Explanation
The correct answer is choice C. Dry, cracked skin.
Choice A rationale:
Increased subcutaneous fat is more commonly seen in full-term infants, but post-term infants (born after 42 weeks) often have decreased subcutaneous fat due to the aging placenta’s reduced efficiency in nutrient delivery.
Choice B rationale:
Scant scalp hair is typically seen in preterm infants. Post-term infants usually have more developed features, including more scalp hair.
Choice C rationale:
Dry, cracked skin is a common finding in post-term infants because the protective vernix caseosa, which covers the skin in utero, has often been shed by this stage. The prolonged exposure to amniotic fluid can lead to skin that appears dry, cracked, and peeling.
Choice D rationale:
Copious vernix is usually seen in preterm infants. By 42.5 weeks, most of the vernix has been absorbed or shed, leading to the dry skin observed in post-term infants.
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