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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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 B
Explanation
Choice A reason:
Initiating pushing in a client with suspected placenta previa is contraindicated. Placenta previa is a condition where the placenta covers the cervix, and pushing could lead to severe bleeding and compromise both the mother and the fetus. The normal labor process involves pushing only after full cervical dilation, and in the case of placenta previa, this could exacerbate the condition.
Choice B reason:
Preparation for cesarean birth is the correct action when placenta previa is suspected. With placenta previa, vaginal delivery could cause significant hemorrhage due to the placenta's position over the cervical opening. A cesarean birth bypasses the cervix, thereby avoiding disruption of the placenta and preventing excessive bleeding.
Choice C reason:
Magnesium sulfate is used in obstetrics to prevent seizures in preeclampsia and to delay preterm labor, not for placenta previa. While it is important to manage the client's overall condition, magnesium sulfate would not address the immediate concern of potential hemorrhage due to placenta previa.
Choice D reason:
An examination to determine cervical status in the presence of placenta previa should be avoided unless absolutely necessary and performed under controlled conditions, such as in an operating room where a cesarean delivery can be performed if needed. Digital cervical examinations can dislodge the placenta and cause bleeding.
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