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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason:
Fetal head compression is incorrect, as this factor can cause early decelerations in the fetal heart rate. Early decelerations are symmetrical decreases in the FHR that mirror the contractions, which indicate fetal head compression and vagal stimulation. Fetal head compression occurs as the fetus descends into the birth canal and does not pose a threat to the fetal well-being.

Choice B reason:
Polyhydramnios is incorrect, as this factor can cause variable or late decelerations in the fetal heart rate, depending on the underlying cause. Polyhydramnios refers to an excessive amount of amniotic ﬂuid, which can result from fetal anomalies, maternal diabetes, multiple gestation, or other conditions. Polyhydramnios can cause umbilical cord prolapse, uterine overdistension, or placental abruption, leading to reduced blood ﬂow and oxygen delivery to the fetus.

Choice C reason:
Maternal fever is incorrect, as this factor can cause late decelerations in the fetal heart rate. Late decelerations are symmetrical decreases in the FHR that begin after the peak of the contraction and return to baseline after the contraction ends, which indicate uteroplacental insufficiency. Maternal fever can increase maternal and fetal metabolism and oxygen demand, leading to fetal hypoxia and acidosis.

Choice D reason:
Umbilical cord compression is correct, as this factor can cause variable decelerations in the fetal heart rate. Variable decelerations are abrupt decreases in the FHR that vary in onset, duration, and depth, which indicate umbilical cord compression and reduced blood ﬂow to the fetus. Umbilical cord compression can occur due to cord prolapse, nuchal cord, short cord, or other causes. The nurse should reposition the client, administer oxygen, and prepare for delivery if indicated.

A. Hematuria B. Pelvic pain C. Pink lochia D. Bradycardia

Correct Answer is B

Explanation

Choice A reason: Hematuria is blood in the urine. It is not a symptom of endometritis, which is an inﬂammation or infection of the uterine lining. Hematuria can have many other causes, such as urinary tract infections, kidney stones, bladder cancer, or trauma.

Choice B reason: Pelvic pain is one of the most common symptoms of endometritis. It can be caused by the inﬂammation or infection of the uterine lining, which can also spread to other pelvic organs. Pelvic pain can be dull, sharp, cramping, or constant, and it may worsen with movement or intercourse¹³.

Choice C reason: Pink lochia is normal vaginal discharge after childbirth. It consists of blood, mucus, and tissue from the uterus. It usually lasts for a few weeks and gradually changes color from red to pink to brown to white. Pink lochia is not a sign of endometritis, unless it is foul-smelling, heavy, or persists beyond six weeks.

Choice D reason: Bradycardia is a slow heart rate, usually below 60 beats per minute. It is not a symptom of endometritis, which can cause fever and tachycardia (fast heart rate). Bradycardia can have many other causes, such as heart disease, medication side eﬀects, hypothyroidism, or electrolyte imbalance.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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