A nurse is collecting data from a client who is 24 hr postpartum. Which of the following findings should the nurse expect?

Fundus soft, 2 fingerbreadths below the umbilicus

Fundus firm, 1 fingerbreadth below the umbilicus

Fundus firm, 4 fingerbreadths above the umbilicus

Fundus soft, to the right of the umbilicus

Answer and Explanation

The Correct Answer is B

Choice A reason: Fundus soft, 2 fingerbreadths below the umbilicus is incorrect, as this finding indicates uterine atony and subinvolution. The fundus is the upper part of the uterus that can be palpated through the abdomen after birth. The fundus should be firm and midline to indicate adequate uterine contraction and involution. A soft or boggy fundus can increase the risk of hemorrhage and infection.

Choice B reason: Fundus firm, 1 fingerbreadth below the umbilicus is correct, as this finding indicates normal uterine contraction and involution. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one fingerbreadth per day. A firm and midline fundus can prevent excessive bleeding and promote healing.

Choice C reason: Fundus firm, 4 fingerbreadths above the umbilicus is incorrect, as this finding indicates a higher than expected fundal height for a client who is 24 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 D reason: Fundus soft, to the right of the umbilicus is incorrect, as this finding indicates uterine atony and bladder distension. The fundus should be firm and midline to indicate adequate uterine contraction and involution. A deviated fundus can indicate bladder distension, which can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection.

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Correct Answer is A

Explanation

Choice A reason:

Panting can help prevent premature pushing and reduce the risk of cervical edema or laceration. The client should be instructed to take short, shallow breaths through her mouth during contractions until she reaches 10 cm of dilation.

Choice B reason:

Assessing the perineum for signs of crowning is not a priority at this stage, as the fetus is not yet at a low enough station to be visible. Crowning usually occurs when the fetus is at +4 or +5 station.

Choice C reason:

Assisting the client into a comfortable position is important, but it does not address the urge to push. The client should be encouraged to change positions frequently to promote fetal descent and comfort.

Choice D reason:

Helping the client to the bathroom to empty her bladder is not advisable, as it can increase the risk of cord prolapse or rupture of membranes. The client should have an indwelling catheter inserted if she is unable to void spontaneously.

A. Fundal consistency B. Fetal heart rate C. Urinary output D. Blood pressure

Correct Answer is A

Explanation

Choice A reason: Fundal consistency is correct, as this finding can indicate the eﬀectiveness of oxytocin in stimulating uterine contraction and preventing postpartum hemorrhage. Oxytocin is a uterotonic agent that can enhance or augment uterine contractility and involution. The nurse should monitor the fundal height, consistency, and position and report any signs of uterine atony or excessive bleeding.

Choice B reason: Fetal heart rate is incorrect, as this finding is not relevant for a client who has already delivered the baby. Fetal heart rate can indicate the fetal well-being and response to labor, but it is not aﬀected by oxytocin administration after birth. The nurse should monitor the newborn's vital signs and appearance and report any signs of distress or infection.

Choice c reason: Urinary output is incorrect, as this finding is not specific for evaluating the eﬀectiveness of oxytocin. Urinary output can indicate the client's renal function and ﬂuid balance, but it can be inﬂuenced by many other factors, such as ﬂuid intake, bladder distension, or epidural anesthesia. The nurse should monitor the client's intake and output and report any signs of oliguria or retention.

Choice D reason: Blood pressure is incorrect, as this finding is not specific for evaluating the eﬀectiveness of oxytocin. Blood pressure can indicate the client's hemodynamic status and response to blood loss, but it can be inﬂuenced by many other factors, such as pain, anxiety, preeclampsia, or medication. The nurse should monitor the client's vital signs and ﬂuid balance and report any signs of hypotension or hypertension

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A nurse is collecting data from a client who is 24 hr postpartum. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate eﬀectiveness of this medication?

Correct Answer is A

Explanation

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