A nurse is collecting data from a client who is 20 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

Positive Homans' sign

Full, firm breasts

Firm fundus at midline

Lochia serosa

Answer and Explanation

The Correct Answer is C

A.   Homans' sign is a test for deep vein thrombosis and is not a normal postpartum finding.
B.   Full, firm breasts typically occur a few days after delivery when milk production begins, not at 20 hours postpartum.
C.   A firm fundus at the midline is an expected finding in the immediate postpartum period, indicating that the uterus is contracting and involuting properly.
D.   Lochia serosa (pinkish-brown discharge) is a normal finding around 3 to 10 days postpartum, but it is not typically present at 20 hours postpartum.

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Correct Answer is A

Explanation

A. At 12 weeks of gestation, the nurse should expect to find the fetal heart tones in the suprapubic area. This is where the uterus is located at this early stage of pregnancy.
B. This is not the correct location for auscultating fetal heart tones at 12 weeks of gestation. The umbilical area is not the typical location for auscultating fetal heart tones at this stage.
C. This is not the correct location for auscultating fetal heart tones at 12 weeks of gestation. At this stage, the nurse should expect to find fetal heart tones in the suprapubic region.
D. This is not the correct location for auscultating fetal heart tones at 12 weeks of gestation. The liver is typically not involved in auscultating fetal heart tones at this stage.

A. Recurrent variable deceleration of the FHR B. Uterine contractions every 6 min C. Uterine contractions lasting 30 to 45 seconds D. Moderate variability of the FHR

Correct Answer is A

Explanation

A. Recurrent variable decelerations of the fetal heart rate (FHR) are concerning and can indicate fetal distress.
B. Uterine contractions every 6 minutes may not provide effective progress in labor, but it is not indicative of fetal distress.
C. Uterine contractions lasting 30 to 45 seconds are within the normal range for labor.
D. Moderate variability of the FHR is a reassuring sign and indicates that the fetus is tolerating labor well.

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A nurse is collecting data from a client who is 20 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

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