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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Nifedipine does not directly affect platelet count.
B. Nifedipine is a calcium channel blocker used to lower blood pressure. Monitoring for a decrease in blood pressure is essential.
C. Nifedipine does not typically cause a significant decrease in fetal heart rate (FHR).
D. While nifedipine may impact urinary output indirectly through blood pressure regulation, it is not the primary therapeutic effect to monitor.
Correct Answer is A
Explanation
A. At 12 weeks of gestation, the uterus has enlarged but is still mostly within the pelvis. Fetal heart tones are best auscultated over the suprapubic area using a Doppler, as the fundus has not yet risen to the level of the umbilicus.
B. The umbilical area corresponds approximately to 20 weeks gestation, so the fetal heart tones would not be audible there at 12 weeks.
C. Auscultating above the iliac crest would likely be too high at 12 weeks, as the uterus has not yet reached this level.
D. The area below the liver border on the right abdomen is too high for early gestation; fetal heart tones would not be reliably heard in this location at 12 weeks.
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