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 D
Explanation
Choice A Reason:
Tocolytic therapy is not indicated for a client with a post-term pregnancy. Tocolytics are medications used to suppress premature labor, and a pregnancy at 42 weeks is considered post-term, not preterm.
Choice B Reason:
Braxton-Hicks contractions are normal occurrences during pregnancy and do not indicate preterm labor. They are often referred to as "false labor" because they do not lead to cervical dilation or effacement. Therefore, tocolytic therapy is not necessary.
Choice C Reason:
Administering tocolytic therapy in the case of fetal death is not appropriate. Tocolytics are used to delay preterm labor to allow for fetal maturation or to prolong pregnancy to administer corticosteroids for fetal lung development, which is not applicable in this scenario.
Choice D Reason:
Tocolytic therapy is appropriate for a client experiencing preterm labor at 26 weeks of gestation. The goal of tocolytic therapy is to delay delivery to allow for the administration of corticosteroids to accelerate fetal lung maturity or to transfer the client to a facility equipped for premature infants.
Correct Answer is C
Explanation
Choice A rationale: Establishing IV access is necessary for potential fluid or blood replacement, but it is not the immediate priority over assessing the current physiological status of the fetus.
Choice B rationale: Monitoring the amount and color of vaginal bleeding is a vital assessment, but it does not provide direct information regarding the fetal response to the placental complication.
Choice C rationale: Assessing the fetal heart rate via external monitoring is the priority to ensure fetal well-being and detect distress, as the fetus is at high risk for hypoxia in placenta previa.
Choice D rationale: Glucocorticoids are administered to promote fetal lung maturity in anticipation of a preterm birth, but this intervention occurs after the initial assessment of fetal and maternal stability.
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