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 B
Explanation
Choice A reason: Apply warm, moist soaks to the client's lower legs is incorrect, as this action is not effective for preventing thrombophlebitis. Warm, moist soaks can provide comfort and reduce inflammation, but they do not improve blood circulation or prevent clot formation.
Choice B reason: Have the client ambulate frequently in the hallway is correct, as this action can prevent thrombophlebitis by improving venous return and preventing stasis. The nurse should encourage and assist the client to ambulate early and frequently after a cesarean birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide support as needed.
Choice C reason: Keep the client on bed rest is incorrect, as this action can increase the risk of thrombophlebitis by reducing blood flow and promoting stasis. Bed rest can also delay wound healing and increase the risk of infection and deconditioning. The nurse should avoid keeping the client on bed rest unless absolutely necessary.
Choice D reason: Place pillows under the client's knees while she is resting in bed is incorrect, as this action can impair blood circulation and increase the risk of thrombophlebitis. Placing pillows under the knees can cause pressure on the popliteal veins and reduce venous return. The nurse should advise the client to avoid crossing their legs or placing pillows under their knees while resting in bed.
Correct Answer is A
Explanation
Expressions of excitement are typical during the dependent, taking-in phase, which lasts for the first 24 to 48 hr after delivery. The client may relive and review her labor and delivery experience, and may need reassurance and validation from others.
Choice B reason:
Lack of appetite is not an expected finding during the dependent, taking-in phase, as the client may have increased hunger and thirst after delivery. The nurse should encourage adequate nutrition and hydration to promote healing and lactation.
Choice C reason:
Eagerness to learn newborn care skills is more characteristic of the dependent-independent, taking-hold phase, which begins around the third day postpartum. During this phase, the client becomes more confident and interested in caring for herself and her newborn.
ChoiceD reason:
Focus on the family unit and its members is more characteristic of the interdependent, letting-go phase, which occurs after the first week postpartum. During this phase, the client redefines her role within the family and society, and integrates the newborn into her life.
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