A nurse is collecting data from a client who is 12 hr postpartum following a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client's abdomen?
Three fingerbreadths above the umbilicus
One fingerbreadth above the symphysis pubis
At the level of the umbilicus
To the right of the umbilicus
The Correct Answer is C
Choice A reason: Three fingerbreadths above the umbilicus is incorrect, as this position indicates a higher than expected fundal height for a client who is 12 hr postpartum. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one fingerbreadth per day. A high fundal height can indicate uterine atony, retained placental fragments, or bladder distension.
Choice B reason: One fingerbreadth above the symphysis pubis is incorrect, as this position indicates a lower than expected fundal height for a client who is 12 hr postpartum. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one finger-breadth per day. A low fundal height can indicate uterine inversion, which is a rare but life-threatening complication.
Choice C reason: At the level of the umbilicus is correct, as this position indicates a normal and expected fundal height for a client who is 12 hr postpartum. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one finger-breadth per day. A midline and firm fundus indicates adequate uterine contraction and involution.
Choice D reason: To the right of the umbilicus is incorrect, as this position indicates a deviated fundus for a client who is 12 hr postpartum. The fundus should be midline and not displaced to either side. A deviated fundus can indicate bladder distension, which can interfere with uterine contraction and involution. The nurse should assist the client to empty their bladder and reassess the fundal position.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: While ice packs can help reduce swelling and discomfort, they are not essential for preventing infection.
Choice B reason: Sit on an inflatable donut to protect the perineum is incorrect, as this can increase pressure and blood flow to the perineum and delay healing. The nurse should advise the client to avoid sitting on hard or uneven surfaces and to use a pillow or a cushion for comfort.
Choice C reason: Perform hand hygiene before and after voiding is correct, as this can prevent contamination and infection of the perineal area. The nurse should instruct the client to wash their hands with soap and water or use an alcohol-based hand sanitizer before and after using the toilet.
Choice D reason: Blot the perineal area dry after voiding is correct, as this can keep the perineal area clean and dry and prevent irritation and infection. The nurse should instruct the client to use a clean, soft cloth or tissue and gently pat or blot the perineal area from front to back after voiding.
Choice E reason: Clean the perineal area from front to back is correct, as this can prevent bacteria from entering the vagina or urethra and causing infection. The nurse should instruct the client to use a peri-botle filled with warm water and squirt it over the perineal area from front to back after each voiding or bowel movement. The client should also change their perineal pad frequently and dispose of it properly.
Correct Answer is B
Explanation
Choice A reason: Perform fundal massage is incorrect, as this action is not indicated for a client who has a firm and midline fundus. Fundal massage is used to stimulate uterine contraction and prevent hemorrhage in clients who have a boggy or deviated fundus.
Choice B reason: Assist the client to ambulate is correct, as this action can promote lochia drainage and prevent pooling of blood in the vagina. The nurse should encourage the client to ambulate early and frequently after birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide assistance as needed.
Choice C reason: Check for blood under the client's butock is incorrect, as this action is not necessary for a client who has a small amount of lochia rubra on the perineal pad. Lochia rubra is normal and expected in the first few days after birth, and it indicates that the placental site is healing. The nurse should check for blood under the butock only if there is suspicion of excessive bleeding or concealed hemorrhage.
Choice D reason: Increase the rate of the IV fluids is incorrect, as this action is not indicated for a client who has a small amount of lochia rubra on the perineal pad. Increasing the rate of IV fluids can cause fluid overload and electrolyte imbalance in the client. The nurse should maintain the IV fluids at the prescribed rate and monitor the client's intake and output.
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