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 A
Explanation
Choice A reason: A precipitous birth is a delivery that occurs in less than 3 hours from the onset of labor. This can cause uterine atony, which is the failure of the uterus to contract and compress the blood vessels after the placenta is delivered. Uterine atony is the most common cause of postpartum hemorrhage²³.
Choice B reason: A small for gestational age newborn is not a risk factor for postpartum hemorrhage. It may be associated with other conditions, such as placental insufficiency or intrauterine growth restriction, but these do not directly increase the risk of bleeding after delivery.
Choice C reason: A two-vessel umbilical cord is a cord that has one artery and one vein instead of the normal two arteries and one vein. This can be a marker for congenital anomalies or placental abnormalities, but it does not increase the risk of postpartum hemorrhage by itself.
Choice D reason: Gestational hypertension is a condition where the blood pressure rises above 140/90 mm Hg after 20 weeks of pregnancy. It can lead to complications such as preeclampsia, eclampsia, or HELLP syndrome, which can affect the clotting system and cause bleeding disorders. However, gestational hypertension alone does not increase the risk of postpartum hemorrhage unless it is associated with these severe conditions¹⁴.
Correct Answer is A
Explanation
Choice A reason: The client is Rh negative and the newborn is Rh positive is correct, as this finding indicates a risk of Rh incompatibility and sensitization. Rh incompatibility occurs when the mother has Rh-negative blood and the baby has Rh-positive blood, which can cause maternal antibodies to atack the fetal red blood cells. Sensitization occurs when the maternal antibodies cross the placenta and enter the fetal circulation, which can cause hemolytic disease of the newborn. The nurse should administer Rho(D) immune globulin to prevent sensitization and protect future pregnancies.
Choice B reason: The client is Rh negative and the newborn is Rh negative is incorrect, as this finding does not indicate a risk of Rh incompatibility or sensitization. If both the mother and the baby have Rh-negative blood, there is no antigen-antibody reaction and no need for Rho(D) immune globulin.
Choice C reason: The client is Rh positive and the newborn is Rh positive is incorrect, as this finding does not indicate a risk of Rh incompatibility or sensitization. If both the mother and the baby have Rh-positive blood, there is no antigen-antibody reaction and no need for Rho(D) immune globulin.
Choice D reason: The client is Rh positive and the newborn is Rh negative is incorrect, as this finding does not indicate a risk of Rh incompatibility or sensitization. If the mother has Rh-positive blood and the baby has Rh- negative blood, there is no antigen-antibody reaction and no need for Rho(D) immune globulin.
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