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

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason: Requesting photo identification from the grandmother is a standard security procedure in many hospitals to ensure the safety of the newborn. However, this option alone does not address the hospital's policy regarding who is permitted to transport infants. Typically, only hospital staff are allowed to move infants within the facility to ensure their safety and security.

Choice B reason: This choice aligns with common hospital policies that require a staff member, such as a nurse, to transport newborns. It ensures that the baby remains under the care of trained personnel during transport and helps prevent potential mix-ups or security issues. The nurse's offer to take the baby to the room upon the mother's request also supports family involvement in the care process while maintaining safety protocols.

Choice C reason: Allowing the grandmother to push the baby to the room in a wheeled bassinet may seem convenient, but it is not typically permitted due to safety and security protocols. Hospitals often have strict regulations about who can transport babies to prevent abductions and ensure that the infant is always accompanied by a staff member.

Choice D reason: While it may be a heartwarming gesture for the grandmother to carry her grandchild, it is not an appropriate response by the nurse. Newborns should be transported in a secure manner, which usually means being in a bassinet or held by hospital staff. Personal carrying increases the risk of falls or other accidents.

A. Cervical dilation B. Amniotic fluid in the vaginal vault C. Report of pain above the umbilicus D. Brownish vaginal discharge

Correct Answer is A

Explanation

Choice A reason:
Cervical dilation is a definitive sign that labor has begun. During labor, the cervix dilates to allow the baby to pass through the birth canal. The process of cervical dilation begins gradually and progresses until it reaches 10 cm, which is considered full dilation. In a primigravida, or a woman who is pregnant for the first time, this process can take longer compared to women who have given birth before.

Choice B reason:
The presence of amniotic fluid in the vaginal vault could indicate that the client's water has broken, which can be a sign of labor. However, it is not a definitive sign of labor on its own, as the membranes can rupture before labor begins (prelabor rupture of membranes). It is also possible for a woman to have a leak of amniotic fluid without being in active labor.

Choice C reason:
Pain above the umbilicus is not typically associated with labor. Labor pains, or contractions, are usually felt as a tightening or cramping sensation that starts in the back and moves to the front of the abdomen. The pain is more commonly located in the lower abdomen and pelvic area.

Choice D reason:
A brownish vaginal discharge, often referred to as "bloody show," can be a sign that labor is approaching, but it does not confirm that labor has begun. The bloody show is caused by the expulsion of the mucus plug that blocks the cervical canal during pregnancy. While it indicates that the cervix is starting to change, it can occur days before labor starts.

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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?

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