The nurse assesses the postpartum client's fundal height and tone in the first 24 hours. Which action will the nurse take to correctly assess the uterine fundus?

Placing index and middle fingers across the uterus

Placing a gloved hand just above the symphysis pubis

Palpating the abdomen while feeling the uterine fundus

Massaging the fundus vigorously to expel any blood clots

Answer and Explanation

The Correct Answer is C

A.   Placing fingers across the uterus is not a standard technique for assessing the uterine fundus postpartum. Palpation is typically performed on the abdomen.
B.   Placing a gloved hand just above the symphysis pubis is more related to assessing descent and engagement of the fetal head during labor, not uterine fundal height.
C.   Palpating the abdomen while feeling the uterine fundus allows the nurse to assess the fundal height, tone, and position.
D.   Massaging the fundus vigorously to expel blood clots is not a recommended practice; gentle massage is performed to assess tone and firmness.

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Correct Answer is B

Explanation

A. Placing the client on her left side is important for optimizing fetal oxygenation but is not the first action when there is a report of a gush of fluid.
B. Notifying the registered nurse (RN) immediately is the first action to ensure prompt assessment and appropriate interventions for possible ruptured membranes.
C. Documenting the time and color of the fluid is important, but immediate notification of the RN takes precedence.
D. Checking fetal heart tones is important but should be done in conjunction with notifying the RN to assess the overall situation and determine the appropriate course of action.

A. Uteroplacental insufficiency B. Maternal hypotension C. Cord compression D. Head compression

Correct Answer is A

Explanation

A. Late decelerations are associated with uteroplacental insufficiency, indicating that the baby is not getting enough oxygen during contractions.
B. Maternal hypotension can lead to decreased perfusion but is more likely associated with variable decelerations.
C. Cord compression is often associated with variable decelerations, not late decelerations.

D. Head compression typically does not cause late decelerations; it may be associated with early decelerations.

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The nurse assesses the postpartum client's fundal height and tone in the first 24 hours. Which action will the nurse take to correctly assess the uterine fundus?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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