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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
It is not necessary to avoid food and fluids the day of the procedure unless specifically instructed by the healthcare provider. Amniocentesis does not typically require fasting; however, some facilities may have different protocols.
Choice B Reason:
A bowel prep protocol is not required for an amniocentesis. This procedure is unrelated to the gastrointestinal tract, and bowel preparation is more commonly associated with procedures like colonoscopy.
Choice C Reason:
Emptying the bladder immediately prior to the procedure is important. A full bladder can obstruct the view of the uterus during ultrasound, which is used to guide the amniocentesis needle. Additionally, an empty bladder reduces the risk of accidental puncture during the procedure.
Choice D Reason:
Washing the abdomen with soap and water the morning of the procedure is a good hygiene practice but is not specifically required for amniocentesis. The area will be cleaned with antiseptic by the healthcare provider before the procedure.
Correct Answer is D
Explanation
Choice a reason:
Temperature monitoring is important in preterm labor to detect infections or inflammations that could complicate the pregnancy. However, while maternal temperature is a vital sign that should be monitored, it is not the priority in this context. The priority is to assess the well-being of the fetus, which is directly indicated by the FHR.
Choice b reason:
Bowel sounds are assessed to ensure gastrointestinal function and to detect potential complications such as ileus or bowel obstruction. In the context of preterm labor, while bowel sounds are part of a comprehensive assessment, they are not the priority over fetal well-being and maternal respiratory status, especially when administering magnesium sulfate, which does not primarily affect gastrointestinal function.
Choice c reason:
Respiratory rate is a critical assessment when administering magnesium sulfate due to the risk of respiratory depression as a side effect of the medication. It is essential to monitor because maternal oxygenation directly affects fetal oxygenation. However, the FHR is a more direct measure of fetal distress and therefore takes priority in this specific assessment.
Choice d reason:
Fetal heart rate (FHR) monitoring is the priority nursing assessment when administering magnesium sulfate IV to a client in preterm labor. Magnesium sulfate can affect uterine contractions and, by extension, fetal oxygenation and well-being. FHR is the most direct indicator of fetal distress, which can occur if the uterus becomes too relaxed and compromises placental blood flow or if there are side effects affecting the mother's cardiovascular status. Therefore, continuous monitoring of FHR is crucial to ensure the fetus is not experiencing distress.
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