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 D
Explanation
The correct answer is choice D. A patient who is 34 weeks pregnant with a breech presentation and ruptured membranes.This is because breech presentation and ruptured membranes are both risk factors for umbilical cord prolapse, which is where the umbilical cord descends through the cervix and is alongside or below the presenting part of the fetus.This can cause fetal hypoxia and distress.
Choice A is wrong because a cephalic presentation and intact membranes are not risk factors for umbilical cord prolapse.
Choice B is wrong because although twins and ruptured membranes are risk factors for umbilical cord prolapse, the risk is lower than in choice D. Choice C is wrong because although a transverse lie is a risk factor for umbilical cord prolapse, the risk is lower than in choice D if the membranes are intact.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today