A nurse is assessing a client who is 1 week postpartum. Which of the following locations should the nurse palpate to assess the client's fundus? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A
B
C
The Correct Answer is {"xRanges":[299.765625,329.765625],"yRanges":[366.609375,396.609375]}
Choice A rationale: This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation).
Choice B rationale: This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation). It then decreases steadily at approximately 1 cm every 24 hours.
Choice C rationale: One-week post-partum, the fundal height should be about 7 cm below the umbilicus (belly button). This means that the uterus is still larger than normal, but it is contracting and healing. The fundal height may vary depending on factors such as the size and position of the baby, the amount of amniotic fluid, and the mother's body type.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A blood pressure of 78/60 mm Hg is indicative of hypotension which is a common complication of anorexia nervosa. However. the low body temperature takes precedence
Choice B rationale:
Weight loss of 20% over the last 6 months is concerning but may not be an immediate indicator for acute care admission.
Choice C rationale:
An apical pulse rate of 50/min is bradycardia, which can be a result of anorexia nervosa, but it may not be an immediate indicator for acute care admission unless the client is symptomatic.
Choice D rationale:
A body temperature of 35.5°C (95.9°F) is below a normal range signfyng hypothermia which needs immedate intervention.
Correct Answer is B
Explanation
Choice A rationale:
Expressing feelings of guilt and survivor's guilt is a common aspect of processing traumatic experiences and can be an important step in healing.
Choice B rationale:
Rationale: This statement indicates that the client is acknowledging and discussing the flashbacks related to the traumatic event. Progression toward positive outcomes in posttraumatic stress disorder (PTSD) often involves recognizing and addressing distressing symptoms.
Choice C rationale:
The preference for independence may indicate resistance to seeking support, which can hinder progress in addressing and managing PTSD symptoms.
Choice D rationale:
Recognizing that the traumatic experience has affected the ability to trust others reflects insight into the impact of the trauma on relationships, which is a step toward positive outcomes.
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