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 A

Explanation

A. The priority is to assess the client's uterine fundus to determine if it is well-contracted. Excessive bleeding could be indicative of uterine atony, and prompt assessment is crucial for intervention.
B. Assisting the client on a bedpan to urinate is a secondary intervention. While a distended bladder can contribute to uterine atony, assessing the fundus comes first to determine the cause.
C. Increasing fluid intake is important for postpartum recovery, but it is not the immediate priority in this situation.
D. Preparing to administer oxytocic medication may be necessary if uterine atony is identified during the fundal assessment. However, assessing the fundus comes first to guide appropriate interventions.

A. Confirming that the newborn is at least 24 hours old. B. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration. C. Assessing the dorsogluteal muscle as the preferred site for injection. D. Confirming that the newborn's mother has been infected with the HBV.

Correct Answer is B

Explanation

A. Confirming that the newborn is at least 24 hours old is not a requirement for administering the HBV vaccine. The vaccine can be given to newborns shortly after birth, typically within 12 hours.
B. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration is correct. This needle size is appropriate for administering vaccines intramuscularly to newborns.
C. Assessing the dorsogluteal muscle as the preferred site for injection is incorrect; the ventrogluteal or vastus lateralis muscles are recommended for intramuscular injections in infants. The dorsogluteal site is not preferred for young children due to the risk of sciatic nerve injury.
D. Confirming that the newborn's mother has been infected with the HBV is not necessary for administering the vaccine, although if the mother is infected, the newborn should receive the HBV vaccine and hepatitis B immunoglobulin (HBIG) within 12 hours of birth.

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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

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Correct Answer is B

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