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 B

Explanation

Choice A reason: The cervix is eﬀaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical eﬀacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.

Choice B reason: The cervix is dilated 3 cm, it is eﬀaced 30%, and the presenting part is 1 cm above the ischial spines is correct, as this follows the correct order and measurement of cervical assessment. Cervical dilation, eﬀacement, and station are recorded in that order to describe the progress of labor. Station refers to the relationship between the presenting part of the fetus and the maternal pelvis, measured by the level of the ischial spines. A negative station means that the presenting part is above the spines, while a positive station means that it is below.

Choice C reason: The cervix is eﬀaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical eﬀacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.

Choice D reason: The cervix is dilated 3 cm, it is eﬀaced 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not match the documentation of station. A negative station means that the presenting part is above the spines, while a positive station means that it is below.

A. 'Lochia can pool in the vagina while you lie in bed.' B. 'You might have retained fragments of your placenta.' C. 'The amount of lochia increases during the postpartum period.' D. 'Urinary tract infections are associated with increased lochia.'

Correct Answer is A

Explanation

Choice A reason: This is the most appropriate response because it reassures the client that the amount of lochia she passed is normal and expected after lying down for a long time. Lochia is the vaginal discharge that occurs after childbirth, consisting of blood, mucus, and uterine tissue. It usually decreases in amount and changes in color over time, from red to pink to brown to yellow.

Choice B reason: This is an incorrect response because it implies that the client has a complication that requires further evaluation. Retained placental fragments can cause excessive bleeding, infection, and uterine atony. The nurse should not alarm the client with this possibility without evidence.

Choice C reason: This is an incorrect response because it contradicts the normal patern of lochia. The amount of lochia usually decreases during the postpartum period, not increases. If the client has an increase in lochia, it could indicate a problem such as infection, subinvolution, or hemorrhage.

Choice D reason: This is an incorrect response because it confuses the client with unrelated information. Urinary tract infections are not associated with increased lochia. They are caused by bacteria entering the urinary tract and can cause symptoms such as dysuria, frequency, urgency, and hematuria. The nurse should not suggest that the client has a urinary tract infection without evidence.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?

Correct Answer is B

Explanation

A nurse is assisting a client out of bed for the first time since delivery. The client becomes frightened when she passes a large amount of lochia. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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