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.

Answer and Explanation

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.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A reason:

Hypertonic is not a type of cerebral palsy, but a term that describes increased muscle tone or stiffness. Hypertonicity can be a symptom of spastic cerebral palsy, which is the most common type of the disorder.

Choice B reason:

Spastic is a type of cerebral palsy that affects about 80% of people with the disorder. People with spastic cerebral palsy have stiff and jerky movements due to increased muscle tone.

Spastic cerebral palsy can be further classified by the body parts affected, such as spastic hemiplegia, spastic diplegia or spastic quadriplegia.

Choice C reason:

Hypotonic is a type of cerebral palsy that affects muscle tone and posture. People with hypotonic cerebral palsy have low muscle tone or floppiness, which makes them appear limp and relaxed. Hypotonic cerebral palsy can affect the whole body or specific parts, such as the trunk, limbs or face.

Choice D reason:

Ataxic is a type of cerebral palsy that affects balance and coordination. People with ataxic cerebral palsy have difficulty with precise movements, such as writing, buttoning a shirt or reaching for a book. They may also walk in an unsteady manner or have problems with depth perception.

Choice E reason:

Mixed is a type of cerebral palsy that includes symptoms of more than one type of the disorder. For example, a person with mixed cerebral palsy may have both spastic and dyskinetic movements, or both ataxic and hypotonic features. Mixed cerebral palsy is usually caused by damage to multiple areas of the brain.

A. "I don't need the bath demonstration. I know how to do it.". B. "Do you think you could keep him in the nursery for the next feeding so I can get some sleep?.". C. "I just wish he had more hair. I'm going to have to keep a hat on his head till he grows some.". D. "He's got my husband's nose, that's for sure.".

Correct Answer is C

Explanation

Choice A reason:

This statement does not indicate inhibition of parental attachment. The client may have prior experience or knowledge of bathing a newborn and may not need the demonstration. The nurse should respect the client's autonomy and confidence in this skill.

Choice B reason:

This statement does not indicate inhibition of parental attachment. The client may be exhausted from the labor and delivery process and may need some rest to recover. The nurse should support the client's request and ensure that the newborn is well cared for in the nursery.

Choice C reason:

This statement indicates inhibition of parental attachment. The client expresses dissatisfaction with the newborn's appearance and implies that the newborn is not attractive enough. The nurse should explore the client's feelings and expectations about the newborn and provide reassurance and education about normal variations in newborn features.

Choice D reason:

This statement does not indicate inhibition of parental attachment. The client recognizes a family resemblance in the newborn and expresses a positive connection with the newborn and the partner. The nurse should acknowledge the client's observation and encourage further bonding with the newborn.

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A nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What are the different types of Cerebral Palsy? (Select All that Apply.).

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as a possible indicator of inhibition of parental attachment?

Correct Answer is C

Explanation

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