A nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect?
Fundus soft, 2 fingerbreadths below the umbilicus.
Fundus firm, 2 fingerbreadths above the umbilicus.
Fundus soft, to the right of the umbilicus.
Fundus firm, at the level of the umbilicus.
The Correct Answer is D
Choice A reason:
A soft fundus indicates uterine atony, which is a lack of muscle tone that can lead to postpartum hemorrhage. A soft fundus is an abnormal finding and should be reported to the provider. The fundus should be firm and contracted to prevent bleeding.
Choice B reason:
A fundus that is 2 fingerbreadths above the umbilicus is too high for a client who is 12 hours postpartum. The fundus should descend about 1 centimeter per hour after delivery and should be at the level of the umbilicus at 12 hours postpartum. A high fundus could indicate retained placental fragments or a full bladder, both of which can interfere with uterine contraction and cause bleeding.
Choice C reason:
A fundus that is deviated to the right of the umbilicus is also an abnormal finding for a client who is 12 hours postpartum. A deviated fundus could indicate a full bladder, which can displace the uterus and prevent it from contracting properly. The fundus should be at the midline of the abdomen.
Choice D reason:
A fundus that is firm and at the level of the umbilicus is a normal finding for a client who is 12 hours postpartum. This indicates that the uterus is involuting (returning to its pre-pregnancy size and shape) and that there is no excessive bleeding. The nurse should expect this finding and document it accordingly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Administering methylergometrine to the client is not the first action the nurse should take. Methylergometrine is a medication that stimulates uterine contractions and can help reduce postpartum bleeding. However, it can also cause hypertension and should be used with caution in clients with high blood pressure. Furthermore, the nurse should first identify and address the cause of the boggy and deviated fundus before giving any medication.
Choice B reason:
Assisting the client to void is the first action the nurse should take. A full bladder can displace the uterus and prevent it from contracting properly, leading to uterine atony and bleeding.
The nurse should help the client empty her bladder by encouraging her to use the bathroom, providing privacy, running water, or using a bedpan. This can help the uterus return to its normal position and tone.
Choice C reason:
Inserting an indwelling urinary catheter is not the first action the nurse should take. A urinary catheter can be used to drain the bladder if the client is unable to void or has a large amount of residual urine. However, it can also increase the risk of infection and trauma to the urethra
and bladder. The nurse should first try noninvasive methods to help the client void, such as those mentioned in choice B.
Choice D reason:
Obtaining a stat hemoglobin level is not the first action the nurse should take. A hemoglobin level can indicate the extent of blood loss and the need for transfusion or other interventions. However, it is not a priority over restoring uterine tone and preventing further bleeding. The nurse should first assist the client to void and then massage the fundus if it remains boggy.
Correct Answer is B
Explanation
Choice A reason:
Using illicit drugs is not a known cause of congenital hip dysplasia. Illicit drugs may have other harmful effects on the baby, but they do not affect the formation of the hip joint.
Choice B reason:
Unknown. The exact cause of congenital hip dysplasia is not clear. Both genetic and environmental factors seem to play a role in the development of the disorder. Some risk factors include being female, firstborn, breech position, family history, and tight swaddling.
Choice C reason:
Being in nursing school is not a cause of congenital hip dysplasia. This is an irrelevant and incorrect choice.
Choice D reason:
Drinking too much is not a cause of congenital hip dysplasia. Alcohol consumption during pregnancy may increase the risk of fetal alcohol syndrome and other complications, but it does not affect the formation of the hip joint.
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