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. This is not appropriate for the taking-in stage, as the woman may not be ready to absorb new information or focus on self-care. She may need more verbal instruction and demonstration from the nurse.
B. The taking-in stage is a period of passive, dependent behavior in which the woman reviews her childbirth experience and adjusts to the new role of motherhood. She may need to talk about her labor and delivery repeatedly and seek reassurance from others. The nurse should listen attentively and validate her feelings.
C. This is more suitable for the taking-hold stage, which occurs after the taking-in stage. In this stage, the woman becomes more active and independent, and shows interest in learning how to care for herself and her baby.
D. This is also more appropriate for the taking-hold stage, when the woman develops confidence and competence in her maternal role. In the taking-in stage, she may be more focused on her own needs and rely on others to care for the baby.

A. Ensure the infant breastfeeds in the first hour. B. Perform a glucose test for the infant before feeding. C. Administer intravenous dextrose infusion within 2 hours. D. Ensure the infant is fed every hour for the first 24 hours.

Correct Answer is A

Explanation

A. This intervention is correct because it provides the infant with a source of glucose and helps prevent hypoglycemia.
B. A glucose test alone may not provide timely intervention if hypoglycemia is detected.
C. Administering intravenous dextrose infusion is a rapid and effective way to address hypoglycemia, but early breastfeeding should be the priority action.
D. While frequent feeding is beneficial, intravenous dextrose may be necessary for a more immediate impact.

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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

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