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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Feeling for a full bladder is not the first action the nurse should take, although it is important to assess for bladder distension and urinary retention in postpartum clients. A full bladder can displace the uterus and increase the risk of uterine atony and hemorrhage.
Choice B reason:
Checking the client's fundus is the first action the nurse should take, as it can indicate the tone and position of the uterus. A firm and midline fundus indicates adequate uterine contraction and prevents excessive bleeding. A boggy or deviated fundus indicates uterine atony or retained placental fragments, which can cause hemorrhage.
Choice C reason:
Measuring the client's vital signs is not the first action the nurse should take, although it is important to monitor for signs of shock and infection in postpartum clients. Vital signs can be affected by various factors and do not provide a direct assessment of uterine status.
Choice D reason:
Requesting the provider perform a vaginal examination is not the first action the nurse should take, as it can introduce infection and trauma to the perineum. A vaginal examination is only indicated if there is suspicion of cervical or vaginal lacerations or retained placenta.
Correct Answer is A
Explanation
Choice A reason: In 3 to 5 days after delivery is correct, as this is the average time for breast milk production to begin after birth. Breast milk production is stimulated by the drop in progesterone levels that occurs after the placenta is delivered, as well as by the suckling of the baby. The nurse should encourage the client to breastfeed frequently and effectively to promote milk production and prevent engorgement.
Choice B reason: In 6 to 8 days after delivery is incorrect, as this is a longer than average time for breast milk production to begin after birth. Breast milk production usually begins within the first week after birth, although it may vary depending on individual factors. The nurse should assess the client for any factors that may delay or inhibit milk production, such as stress, fatigue, pain, or medication.
Choice C reason: Within 2 days after delivery is incorrect, as this is a shorter than average time for breast milk production to begin after birth. Breast milk production usually begins within the first week after birth, although it may vary depending on individual factors. The nurse should educate the client that before breast milk comes in, the breasts produce colostrum, which is a thick, yellowish fluid that contains antibodies and nutrients for the baby.
Choice D reason: In about 10 days after delivery is incorrect, as this is a longer than average time for breast milk production to begin after birth. Breast milk production usually begins within the first week after birth, although it may vary depending on individual factors. The nurse should assess the client for any factors that may delay or inhibit milk production, such as stress, fatigue, pain, or medication.
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