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 rationale: Vitamin K deficiency in newborns can cause bleeding disorders due to impaired clotting, but it does not cause jaundice. Jaundice is related to bilirubin metabolism, not coagulation pathways.
Choice B rationale: Physiologic jaundice typically appears after 24 hours of life due to immature liver function. Jaundice observed immediately at birth suggests a pathologic cause, not physiologic immaturity.
Choice C rationale: Maternal cocaine abuse may cause neonatal irritability, tremors, or growth restriction, but it is not directly linked to jaundice. Cocaine affects neurobehavioral outcomes, not bilirubin metabolism.
Choice D rationale: Maternal/newborn blood group incompatibility (e.g., ABO or Rh) causes hemolysis of fetal red blood cells, leading to elevated bilirubin levels and jaundice within the first 24 hours—hallmark of pathologic jaundice.
Correct Answer is B
Explanation
Choice A reason:
Immunization for rubella in the third trimester is not recommended because live vaccines are contraindicated during pregnancy due to the theoretical risk to the fetus.
Choice B reason:
The recommended time for rubella immunization is shortly after giving birth. This timing is advised because the vaccine contains a live virus, which could potentially harm the fetus if given during pregnancy. By waiting until after the delivery, there is no risk to the newborn, and the mother can develop immunity before any subsequent pregnancies.
Choice C reason:
While it is important for a woman to have immunity to rubella before getting pregnant, the immunization should not be given during the time she is trying to conceive. Women are advised to avoid pregnancy for at least 28 days after receiving the MMR vaccine, which includes the rubella component, due to the live virus in the vaccine.
Choice D reason:
Immunization for rubella should not be given immediately upon finding out that the client does not have immunity during the first trimester. As mentioned, live vaccines are contraindicated during pregnancy, and the immunization should be postponed until after the birth of the baby.
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