A nurse is caring for a client who is 12 hours postpartum following a vaginal delivery. Which of the following findings should the nurse expect?
Fundus soft, 1 cm to the right of the umbilicus.
Fundus firm, at the level of the umbilicus.
Fundus soft, 2 cm above the umbilicus.
Fundus present, to the left of the umbilicus.
The Correct Answer is B
Choice a reason:
The fundus being soft and to the right of the umbilicus could indicate that the bladder is full and displacing the uterus. This is not an expected finding and would require the nurse to encourage the client to empty her bladder to help the uterus contract and return to its normal position.
Choice b reason:
The expected finding for a client who is 12 hours postpartum is for the fundus to be firm and at the level of the umbilicus. A firm fundus indicates good uterine tone and that the uterus is contracting as it should to return to its pre-pregnancy size. This helps to prevent excessive bleeding and promotes recovery.
Choice c reason:
A fundus that is soft and 2 cm above the umbilicus is not an expected finding at 12 hours postpartum. This could suggest that the uterus is not contracting properly, which could lead to postpartum hemorrhage. The nurse would need to assess further and possibly provide interventions such as fundal massage or medication to encourage uterine contractions.
Choice d reason:
The fundus being present to the left of the umbilicus may indicate that the uterus is not contracting symmetrically or that there is a full bladder displacing the uterus. This finding would prompt the nurse to assess for bladder distention and encourage the client to void to help the uterus contract properly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice a) reason: Pelvic pain is a common symptom of endometritis. The pain is typically located in the lower abdomen and may be associated with uterine tenderness upon physical examination. This symptom, especially when combined with other signs such as fever and foul-smelling lochia, strongly suggests the need for further evaluation for endometritis.
Choice b) reason: Hematuria, or blood in the urine, is not a typical symptom of endometritis. While it could be a sign of other postpartum complications, such as urinary tract infections or bladder injury during childbirth, it does not directly indicate endometritis.
Choice c) reason: A localized area of breast tenderness is more indicative of a breast infection, such as mastitis, especially if associated with breastfeeding. It is not a symptom of endometritis, which affects the uterus and not the breasts.
Choice d) reason: While foul-smelling lochia can be a sign of endometritis, the key is the presence of a foul odor. A moderate amount of dark red lochia alone, without a foul odor, is a normal finding in the immediate postpartum period. It's the transition from rubra (red) to serosa (pink/brown) to alba (yellow/white) that is expected as the uterus heals.
Correct Answer is C
Explanation
Choice A reason:
Precipitous labor is characterized by a labor that progresses rapidly and ends within three hours of its onset. It is not typically associated with painless, bright red vaginal bleeding. This condition is more likely to present with intense, frequent contractions and a rapid change in cervical dilation. Therefore, precipitous labor is not the correct answer in this scenario.
Choice B reason:
Abruptio placentae, also known as placental abruption, is a condition where the placenta detaches from the uterus before delivery. It can cause significant maternal and fetal complications. The classic presentation includes painful bleeding, uterine tenderness, and contractions. Given that the scenario describes painless bleeding, abruptio placentae is less likely to be the correct diagnosis.
Choice C reason:
Placenta previa is a condition where the placenta covers the cervix partially or completely. The hallmark sign of placenta previa is painless, bright red vaginal bleeding, which aligns with the scenario provided. This bleeding can occur spontaneously or be triggered by intercourse or a medical exam. Placenta previa is a serious condition that can lead to maternal and fetal hemorrhage and warrants immediate medical attention. Based on the information provided, placenta previa is the most likely diagnosis for the client described.
Choice D reason:
Threatened abortion refers to vaginal bleeding that occurs in the first 20 weeks of pregnancy, which may indicate a potential miscarriage. Since the client is at 36 weeks gestation, threatened abortion is not a relevant diagnosis for late-term bleeding. Additionally, threatened abortion is often accompanied by abdominal cramping, which is not mentioned in the scenario.
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