A nurse is assessing a client who had a vaginal delivery and notes that her fundus is firm, midline, and 2 cm below the umbilicus.
The nurse should document this finding as which of the following?
Normal involution
Subinvolution
Retained placenta
Endometritis
The Correct Answer is A
The correct answer is choice A. Normal involution.
This means that the uterus is returning to its pre-pregnancy size and position after delivery.
The fundus is the upper part of the uterus and it should be firm, midline, and gradually descend into the pelvis. A fundus that is 2 cm below the umbilicus at 4 hours postpartum is within the normal range.
Choice B. Subinvolution is wrong because it refers to a delayed or incomplete involution of the uterus.
This can result in prolonged bleeding, infection, or retained placental fragments. A fundus that is above the umbilicus, boggy, or displaced to one side may indicate subinvolution.
Choice C. Retained placenta is wrong because it means that some or all of the placenta remains in the uterus after delivery.
This can cause heavy bleeding, infection, or uterine atony. A fundus that is high, soft, or tender may indicate retained placenta.
Choice D. Endometritis is wrong because it means that the lining of the uterus is inflamed due to infection.
This can cause fever, foul-smelling lochia, pelvic pain, or uterine tenderness. A fundus that is enlarged, tender, or malodorous may indicate endometritis.
Normal ranges for fundal height after delivery are:
• Immediately after delivery:
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
The correct answer is choice A and B. The nurse should place the patient in knee-chest or Trendelenburg position to relieve the pressure of the fetal presenting part on the prolapsed cord and improve fetal oxygenation.These positions also allow gravity to help keep the cord in the uterus and prevent further descent.
Choice C is wrong because supine position can worsen cord compression and compromise fetal blood flow.Choice D is wrong because lithotomy position can also increase cord descent and reduce fetal perfusion.Choice E is wrong because Sims position can cause cord prolapse if the membranes are intact or rupture spontaneously.
Normal ranges for fetal heart rate are 110 to 160 beats per minute.Cord prolapse can cause fetal bradycardia with decelerations during contractions due to cord compression.
This is a sign of fetal distress and requires immediate intervention.
Correct Answer is A
Explanation
The correct answer is choice A. Normal involution.
This means that the uterus is returning to its pre-pregnancy size and position after delivery.
The fundus is the upper part of the uterus and it should be firm, midline, and gradually descend into the pelvis.A fundus that is 2 cm below the umbilicus at 4 hours postpartum is within the normal range.
Choice B. Subinvolution is wrong because it refers to a delayed or incomplete involution of the uterus.
This can result in prolonged bleeding, infection, or retained placental fragments.A fundus that is above the umbilicus, boggy, or displaced to one side may indicate subinvolution.
Choice C. Retained placenta is wrong because it means that some or all of the placenta remains in the uterus after delivery.
This can cause heavy bleeding, infection, or uterine atony.A fundus that is high, soft, or tender may indicate retained placenta.
Choice D. Endometritis is wrong because it means that the lining of the uterus is inflamed due to infection.
This can cause fever, foul-smelling lochia, pelvic pain, or uterine tenderness.A fundus that is enlarged, tender, or malodorous may indicate endometritis.
Normal ranges for fundal height after delivery are:
• Immediately after delivery:
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