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 C
Explanation
Choice A Reason:
Iron is not poorly absorbed in infants; in fact, infants absorb iron quite efficiently. Breast milk contains a small amount of iron, but it is highly bioavailable and well-absorbed. When switching to formula, it is important to use iron-fortified options to prevent iron deficiency anemia.
Choice B Reason:
While iron is essential for overall growth and development, including bone growth, it is not the primary reason for emphasizing iron in infant nutrition. The key concern with iron, especially when transitioning from breastfeeding, is the prevention of iron deficiency anemia, which can affect cognitive and motor development.
Choice C Reason:
This is the correct information to include in the teaching. Infants are born with a reserve of iron that begins to deplete around 4 to 6 months of age. It is crucial to introduce iron-fortified formula at this time to ensure the infant continues to receive adequate iron for development and to prevent iron deficiency anemia.
Choice D Reason:
Iron does play a role in the development of the nervous system, which can indirectly affect vision, but it is not specifically known for facilitating the development of vision in infants. The primary concern with iron intake in infants relates to its role in preventing anemia and supporting overall growth and development.
Correct Answer is D
Explanation
Choice A reason:
Reducing exercise to 3 days a week may not be sufficient for managing gestational diabetes. Regular physical activity is an important part of diabetes management because it helps lower blood sugar levels and can improve insulin sensitivity. The American Diabetes Association recommends that pregnant women with gestational diabetes engage in at least 150 minutes of moderate-intensity aerobic activity per week. This can be distributed over at least three days per week, with no more than two consecutive days without exercise.
Choice B reason:
The statement that the client knows she is at increased risk of developing type 2 diabetes is accurate. Women with gestational diabetes have a higher risk of developing type 2 diabetes later in life. Therefore, they should be monitored for diabetes postpartum and in the years following the birth.
Choice C reason:
Taking glyburide, an oral hypoglycemic agent, is a common treatment for gestational diabetes when diet and exercise are not enough to control blood sugar levels. It is usually taken before breakfast to help control blood sugar levels throughout the day.
Choice D reason:
The statement about limiting carbohydrates to 50% of caloric intake indicates a need for further teaching. While it is important to monitor carbohydrate intake, there is no one-size-fits-all recommendation for the percentage of calories that should come from carbohydrates. Dietary needs can vary based on individual factors, and it is generally recommended to follow a balanced diet with carbohydrates coming from whole grains, fruits, vegetables, and legumes. The client should work with a dietitian to determine the appropriate amount of carbohydrates for her specific needs.
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