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/
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The indirect Coombs test is used to screen for antibodies in the mother's blood that could potentially cause hemolytic disease in the newborn if they are Rh-positive. A positive result indicates that the mother has developed antibodies that could cross the placenta and attack the red blood cells of an Rh-positive fetus.
Choice B reason: The indirect Coombs test does not detect Rh-negative antibodies in the newborn's blood. Instead, it is used to detect antibodies in the mother's blood. The direct Coombs test is used to detect antibodies that are already attached to the red blood cells of the newborn.
Choice C reason: The indirect Coombs test does not determine if kernicterus will occur in the newborn. Kernicterus is a form of brain damage that can result from very high levels of bilirubin in a baby's blood. It is not directly related to the presence of antibodies detected by the indirect Coombs test.
Choice D reason: The indirect Coombs test does not determine the presence of maternal antibodies in the newborn's blood. This is assessed by the direct Coombs test, which checks for antibodies bound to the surface of the newborn's red blood cells, indicating that the immune system is attacking them.
Correct Answer is A
Explanation
Choice A reason: When a client in active labor presents with hypotension, as indicated by a blood pressure reading of 82/52 mm Hg, the priority nursing intervention is to assist the client to turn onto her side. This position helps to alleviate pressure on the inferior vena cava, which can be compressed by the gravid uterus, thereby improving venous return and increasing blood pressure. It also enhances uteroplacental perfusion, providing better oxygenation to the fetus.
Choice B reason: While preparation for a cesarean birth may be necessary if there are signs of fetal distress or if the hypotension does not resolve, it is not the first-line intervention for isolated hypotension without other indications.
Choice C reason: Preparing for an immediate vaginal delivery is not the priority action in response to hypotension. The focus should be on stabilizing the mother's blood pressure to ensure safe delivery, whether vaginal or cesarean.
Choice D reason: Assisting the client to an upright position is not advisable in the case of hypotension, as this can further decrease venous return to the heart and exacerbate the low blood pressure.
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