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 D
Explanation
Choice A reason:
A negative rubella titer indicates that the client does not have immunity to the rubella virus. Immunity would be indicated by a positive titer, showing the presence of rubella IgG antibodies in the blood. Therefore, this choice is incorrect.
Choice B reason:
While the client does not have immunity, administering a rubella vaccination during pregnancy is not recommended due to the theoretical risk to the fetus. Vaccinations with live viruses, like the rubella vaccine, are generally avoided during pregnancy.
Choice C reason:
A negative rubella titer does indeed indicate that the client is not currently experiencing a rubella infection, as active infection would be indicated by the presence of rubella IgM antibodies. However, this choice does not address the client's susceptibility to future infection or the need for immunization.
Choice D reason:
The correct interpretation of a negative rubella titer in an antepartum client is that she is not immune to rubella and should receive the rubella immunization after delivery. This is to ensure immunity and prevent the possibility of contracting rubella in future pregnancies, which could be harmful to the fetus.
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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