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 C

Explanation

A. Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.
B. Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.
C. Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.
D. Observing an area of redness on the breast requires nursing assessment and intervention.

A. "I'll apply petroleum jelly to his penis with diaper changes." B. "I'll make sure his diaper is loose in the front." C. "I'll expect the plastic ring to fall off by itself within a couple of days." D. "I'll wash his penis with warm water and mild soap each day."

Correct Answer is B

Explanation

A. Applying petroleum jelly is not recommended with the Plastibell technique as it may interfere with the ring falling off.
B. The client should also keep the diaper loose in the front to prevent pressure or irritation on the penis.
C. The ring to fall off by itself within 5 to 10 days. Do not try to remove it yourself or pull on it.
D. Washing with warm water and mild soap is generally good hygiene but may not be necessary for circumcision care.

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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

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Correct Answer is C

Explanation

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care?

Correct Answer is B

Explanation

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