A nurse is caring for a client who experienced a vaginal delivery 16 hr ago. When palpating the client’s abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

At the level of the umbilicus

2 cm above the umbilicus

One fingerbreadth above the symphysis pubis

To the right of the umbilicus

Answer and Explanation

The Correct Answer is A

A.   The uterine fundus is expected to be at the level of the umbilicus after delivery and descends approximately one fingerbreadth (or 1 cm) per day after delivery.
B.   The uterine fundus would be too high for this time frame.
C. The fundus should reach the level of the symphysis pubis by 10 days postpartum.
D.   The uterine fundus should not be palpated to the right of the umbilicus; it should be midline or slightly to the right. A lateral displacement of the fundus may indicate a full bladder, which can interfere with uterine contraction and increase the risk of bleeding.

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Correct Answer is B

Explanation

A. The ball of the foot is not recommended for heelstick procedures.
B. The outer aspect of the heel is the preferred site. This area has fewer nerve endings and less risk of damaging the bone or cartilage.
C. The area below the fifth toe is not a standard site for a heelstick.
D. The walking surface of the heel should be avoided since it is prone to infection, more sensitive, and may interfere with walking.

A. “I can store my breast milk in the freezer for 3 months.” B. “I can store my breast milk in the refrigerator for 3 months.” C. “I can store my breast milk in the refrigerator for 3 to 5 days.” D. “I can store my breast milk at room temperature for 4 hours.”

Correct Answer is B

Explanation

A. Breast milk can be stored in the freezer for up to 3 months.
B. Storing breast milk in the refrigerator for 3 months is an incorrect statement because breast milk can only be stored in the refrigerator for up to 8 days, not 3 months.
C. Storing breast milk in the refrigerator for 3 to 5 days is a correct statement.
D. Storing breast milk at room temperature for 4 hours is a correct statement.

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A nurse is caring for a client who experienced a vaginal delivery 16 hr ago. When palpating the client’s abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The most serious complication of an infant heelstick is necrotizing osteochondritis resulting from lancet penetration of the bone. What approach should the nurse take when performing the test to prevent this complication?

Correct Answer is B

Explanation

A nurse is discussing the storage of breast milk with a mother whose infant is preterm and in the special care nursery. Which statement indicates that the mother requires additional teaching?

Correct Answer is B

Explanation

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