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:
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. A client who has oligohydramnios.
Oligohydramnios is a condition where there is too little amniotic fluid around the fetus.This can cause the umbilical cord to slip down into the cervix or vagina before the baby, resulting in cord prolapse.
Cord prolapse can cut off the blood and oxygen supply to the baby and cause fetal distress or death.
Choice A is wrong because a client who is pregnant with twins is not at greater risk for cord prolapse unless there is also malpresentation of the fetuses, such as breech or transverse lie.
Choice B is wrong because a client who has gestational hypertension is not at greater risk for cord prolapse unless there is also polyhydramnios, which is excessive amniotic fluid around the fetus.
Choice D is wrong because a client who has placenta previa is not at greater risk for cord prolapse unless there is also artificial rupture of membranes by doctors.
Correct Answer is A
Explanation
The correct answer is choice A. “I will avoid squatting or sitting on the toilet after my water breaks.” This statement indicates that the patient understands how to prevent umbilical cord prolapse, which is a rare but serious complication that occurs when the umbilical cord slips out of the cervix before the baby during labor.This can cut off the baby’s blood and oxygen supply and require immediate delivery.
Choice B is wrong because drinking plenty of fluids does not affect the amniotic fluid level, which is determined by the placenta and the baby’s kidneys.Excessive amniotic fluid (polyhydramnios) can actually increase the risk of umbilical cord prolapse.
Choice C is wrong because monitoring the baby’s movements does not prevent umbilical cord prolapse, although it can help detect fetal distress if the cord is compressed.Decreased fetal movements can have other causes besides cord prolapse, such as fetal sleep cycle, maternal medication, or placental insufficiency.
Choice D is wrong because sleeping on the left side does not prevent umbilical cord prolapse, although it can improve blood flow to the baby and reduce the risk of supine hypotension syndrome.Umbilical cord prolapse can occur regardless of the maternal position.
Normal ranges for amniotic fluid index (AFI) are 5 to 25 cm.Normal ranges for fetal heart rate (FHR) are 110 to 160 beats per minute (bpm).
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