A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

Assist the client to void then reassess the fundus.

Document the findings as within normal limits.

Gently massage the client's fundus.

Encourage the client to ambulate.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Assisting the client to void is a priority intervention in this situation. A full bladder can displace the uterus and prevent it from contracting effectively, leading to a boggy and high- positioned fundus. After the client empties her bladder, the nurse should reassess the fundus to ensure it has descended to its appropriate location, which is usually at or just below the level of the umbilicus.

Choice B rationale:

Documenting the findings as within normal limits is incorrect because a firm, displaced fundus that is 3 cm above the umbilicus is not considered normal. This finding indicates that the uterus is not contracting adequately, and the nurse should take appropriate actions to address the issue.

Choice C rationale:

Gently massaging the client's fundus is not the correct intervention in this case. Massaging a firm fundus could cause uterine irritation and should be avoided. Instead, the nurse should encourage the client to empty her bladder, which often helps the uterus contract and descend to its proper position.

Choice D rationale:

Encouraging the client to ambulate may be helpful in some cases to promote uterine contractions and involution. However, in this situation, the priority is to address the full bladder, as it is a common cause of a displaced and high fundus shortly after delivery.

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Correct Answer is A

Explanation

The correct answer is: A. Hemoglobin 12 g/dL.

Choice A reason:

Hemoglobin levels in newborns are expected to be significantly higher than in adults due to the physiological adaptation to life outside the womb. The normal range for a newborn’s hemoglobin is approximately 14 to 24 g/dL1234. A level of 12 g/dL is below the expected range and could indicate anemia or other underlying conditions that may require further investigation and intervention by the healthcare provider.

Choice B reason:

The glucose level in a newborn can vary, especially within the first few hours after birth. Normal blood glucose levels for a newborn 1 to 2 hours old can be as low as 25 mg/dL and can rise to adult levels (60-100 mg/dL) within the first few days5. A glucose level of 50 mg/dL in a 24-hour-old newborn falls within the acceptable range and would not typically require reporting to the provider unless accompanied by symptoms of hypoglycemia.

Choice C reason:

Bilirubin levels in newborns can be elevated due to the normal breakdown of fetal hemoglobin as the baby’s liver matures. Normal bilirubin levels for a newborn can range from 1.0 to 12.0 mg/dL6. A bilirubin level of 4 mg/dL is within the normal range for a 24-hour-old newborn and is not typically a cause for concern unless there are signs of jaundice or other symptoms.

Choice D reason:

The normal platelet count for a newborn ranges from 150,000 to 450,000/mm³7. A platelet count of 200,000/mm³ is well within the normal range for a newborn and would not need to be reported to the healthcare provider.

A. Check the newborn's temperature every 8 hr. B. Apply moisturizing lotion to the newborn's skin every 4 hr. C. Give the newborn 1 oz of glucose water every 4 hr. D. Reposition the newborn every 2 to 3 hr.

Correct Answer is D

Explanation

Choice A rationale:

Checking the newborn's temperature every 8 hours is not directly related to managing hyperbilirubinemia or phototherapy. Monitoring the newborn's temperature is important, but it should be done more frequently, especially during phototherapy, as infants are at risk of developing hypothermia.

Choice B rationale:

Applying moisturizing lotion to the newborn's skin every 4 hours is not a necessary intervention for hyperbilirubinemia or phototherapy. While skin care is important for all newborns, it is not a specific intervention for this condition.

Choice C rationale:

Giving the newborn 1 oz of glucose water every 4 hours is not an appropriate intervention for hyperbilirubinemia. Glucose water is not a recommended treatment for this condition.

Instead, phototherapy helps break down the bilirubin and promote its elimination from the body.

Choice D rationale:

Repositioning the newborn every 2 to 3 hours is the correct intervention. Repositioning helps ensure even exposure of the baby's skin to the phototherapy lights, maximizing its effectiveness in reducing bilirubin levels. Additionally, repositioning prevents pressure ulcers and promotes comfort for the infant during treatment.

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A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

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