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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice a reason:
Hydration is crucial during pregnancy, especially for those with preeclampsia. Adequate water intake helps maintain blood volume and reduce blood viscosity, which can help manage blood pressure levels. Drinking 48 to 64 ounces of water daily is recommended to support the increased blood volume needed during pregnancy and to help prevent dehydration, which can exacerbate preeclampsia symptoms.

Choice b reason:
While reducing salt intake can be beneficial for managing blood pressure, it is not necessary to completely avoid salting foods during cooking. Instead, moderation is key. Excessive salt can lead to water retention, which can worsen preeclampsia, but some salt is needed for electrolyte balance and proper body function.

Choice c reason:
Protein is an essential nutrient for fetal growth and the repair and maintenance of maternal tissues. A daily intake of 40 to 50 grams of protein is generally recommended during pregnancy. However, for those with preeclampsia, protein needs may be higher due to potential protein loss in the urine. It's important to monitor protein intake and adjust as needed under medical guidance.

Choice d reason:
Limiting the intake of whole grains, raw fruits, and vegetables is not recommended. These foods provide essential nutrients, fiber, and antioxidants that are beneficial for both maternal and fetal health. They should be included as part of a balanced diet unless there are specific dietary restrictions advised by a healthcare provider.

A. Initiation of pushing B. Preparation for cesarean birth C. Magnesium sulfate infusion D. Examination to determine cervical status

Correct Answer is B

Explanation

Choice A reason:
Initiating pushing in a client with suspected placenta previa is contraindicated. Placenta previa is a condition where the placenta covers the cervix, and pushing could lead to severe bleeding and compromise both the mother and the fetus. The normal labor process involves pushing only after full cervical dilation, and in the case of placenta previa, this could exacerbate the condition.

Choice B reason:
Preparation for cesarean birth is the correct action when placenta previa is suspected. With placenta previa, vaginal delivery could cause significant hemorrhage due to the placenta's position over the cervical opening. A cesarean birth bypasses the cervix, thereby avoiding disruption of the placenta and preventing excessive bleeding.

Choice C reason:
Magnesium sulfate is used in obstetrics to prevent seizures in preeclampsia and to delay preterm labor, not for placenta previa. While it is important to manage the client's overall condition, magnesium sulfate would not address the immediate concern of potential hemorrhage due to placenta previa.

Choice D reason:
An examination to determine cervical status in the presence of placenta previa should be avoided unless absolutely necessary and performed under controlled conditions, such as in an operating room where a cesarean delivery can be performed if needed. Digital cervical examinations can dislodge the placenta and cause bleeding.

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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?

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