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 nurse should not allow anyone other than the mother or the father to take the newborn to the mother's room. This is to prevent infant abduction, which is a serious threat in hospitals. The nurse should also verify the identity of the mother or the father before handing over the newborn. The nurse should instruct the grandmother to have the mother call and request for the newborn to be brought to her room.
B. This is incorrect because pushing the baby in a wheeled bassinet is not a secure way of transporting the newborn. The bassinet could be easily taken by someone else or accidentally rolled away. The nurse should always accompany the newborn when moving from one place to another.
C. This is incorrect because carrying the grandchild to the room is also not a secure way of transporting the newborn. The grandmother could be stopped by someone who claims to be a staff member and asked to hand over the newborn. The nurse should never let anyone carry the newborn without proper identification and authorization.
D. This is incorrect because showing photo identification is not enough to prove that the person is related to the newborn. The nurse should only allow the mother or the father to take the newborn, and only after verifying their identity with a wristband or a code. The nurse should not rely on photo identification alone, as it could be forged or stolen.

A. Drying the newborn's skin thoroughly B. Preventing air drafts C. Placing the newborn on a warm surface D. Maintaining ambient room temperature at 24° C (75" F)

Correct Answer is A

Explanation

A. Drying the newborn's skin thoroughly helps reduce evaporative heat loss by removing wetness and promoting warmth.
B. Preventing air drafts is important to reduce convective heat loss.
C. Placing the newborn on a warm surface helps prevent conductive heat loss.
D. Maintaining ambient room temperature is important but does not directly address evaporative heat loss.

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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?

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