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 C
Explanation
This is a condition where there is too little amniotic fluid around the fetus.This increases the risk of umbilical cord prolapse because the cord can easily slip past the presenting part of the fetus and into the cervix or vagina.
This can cause fetal hypoxia and distress due to compression or occlusion of the cord.
Choice A. Transverse lie is wrong because this is a condition where the fetus lies horizontally across the uterus.This can increase the risk of cord prolapse if the membranes rupture and the cord descends alongside or before the fetus.
Choice B. Macrosomia is wrong because this is a condition where the fetus is larger than average.This can decrease the risk of cord prolapse because the presenting part of the fetus is more likely to fill the pelvis and prevent the cord from slipping past.
Choice D. Placenta previa is wrong because this is a condition where the placenta covers part or all of the cervix.This can increase the risk of bleeding during labor, but not necessarily cord prolapse.
Correct Answer is B
Explanation
The correct answer is choice B. Umbilical cord compression.Variable decelerations are the most common type of fetal deceleration and they are caused by compression of the umbilical cord.They vary in shape, duration, and intensity and may not have a constant relationship with uterine contractions.
Choice A is wrong because uteroplacental insufficiency is the cause of late decelerations, not variable decelerations.Uteroplacental insufficiency is a decrease in the blood flow to the placenta that reduces the amount of oxygen and nutrients transferred to the fetus.
Choice C is wrong because maternal hypotension is one of the possible causes of late decelerations, not variable decelerations.Maternal hypotension can reduce the uteroplacental blood flow and cause fetal hypoxia.
Choice D is wrong because fetal head compression is the cause of early decelerations, not variable decelerations.Early decelerations are benign and uniform in shape and they occur when the fetal head is pressed against the cervix during a uterine contraction.
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