A nurse is caring for a client who experienced a vaginal delivery 12 hours ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?
2 cm above the umbilicus
At the level of the umbilicus
One fingerbreadth above the symphysis pubis
To the right of the umbilicus
The Correct Answer is B
The correct answer is choice B. At the level of the umbilicus.
Choice A rationale:
The fundus is typically not found 2 cm above the umbilicus 12 hours postpartum. This position is more common immediately after delivery or in cases of uterine atony or retained placental fragments.
Choice B rationale:
At 12 hours postpartum, the uterine fundus is expected to be at the level of the umbilicus. This indicates normal involution of the uterus, where it contracts and shrinks back to its pre-pregnancy size.
Choice C rationale:
One fingerbreadth above the symphysis pubis is not a typical position for the fundus 12 hours after delivery. This position is more likely several days postpartum as the uterus continues to involute.
Choice D rationale:
The fundus being to the right of the umbilicus may indicate a full bladder, which can push the uterus to one side. This is not a normal finding 12 hours postpartum and would require intervention to empty the bladder.
: https://bchsfoutreach.ucsf.edu/sites/bchsfoutreach.ucsf.edu/files/handouts/Washington%20Hospital%20Postpartum%204-2018.pdf : https://nursekey.com/fundal-palpation-postpartum/
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Correct Answer is A
Explanation
Choice a reason:
A fundus that is palpable to the right of the midline can indicate a distended bladder. After childbirth, the bladder can become distended due to decreased sensitivity, which may be caused by trauma during delivery or the effects of anesthesia. A distended bladder can push the uterus to the side and prevent it from contracting properly, leading to increased bleeding. It's important for the nurse to encourage the client to void to relieve bladder distension and allow the uterus to contract effectively.
Choice b reason:
Less than 2.5 cm of rubra lochia on the perineal pad does not necessarily indicate bladder distension. Lochia rubra is the normal discharge of blood, mucus, and tissue from the uterus after childbirth, and its amount can vary widely among individuals. While heavy lochia can be a sign of postpartum hemorrhage, it is not directly related to bladder distension.
Choice c reason:
Increased thirst in a postpartum client is not a direct indicator of bladder distension. Thirst can be influenced by various factors, including dehydration from labor, breastfeeding, or hormonal changes. While it's important for a postpartum client to stay hydrated, increased thirst alone does not suggest a distended bladder.
Choice d reason:
Frequent uterine contractions reported by the client are not a sign of bladder distension. These contractions, known as afterpains, are normal and occur as the uterus contracts to return to its pre-pregnancy size. While uncomfortable, they are a sign of the uterus working to expel blood and tissue and do not indicate bladder issues.
Correct Answer is B
Explanation
Choice A Reason:
The recommended intake of iron does not necessarily increase during lactation. In fact, the iron requirement may decrease because menstruation usually ceases, reducing iron loss. However, maintaining adequate iron intake is still important for overall health and to support the baby's growth.
Choice B Reason:
Zinc is crucial for immune function, cell division, and growth, making it an important nutrient during lactation. The recommended dietary allowance (RDA) for zinc for lactating women is indeed higher than for non-pregnant, non-lactating women, with an RDA of about 12 mg per day.
Choice C Reason:
While calcium is important for bone health, the recommended intake for lactating women is not as high as 2,000 mg per day. The RDA for calcium for lactating women is about 1,000 mg per day, similar to that for non-lactating women.
Choice D Reason:
The recommended intake of folic acid does not remain the same as for pregnant women. During pregnancy, the RDA for folic acid is higher to prevent neural tube defects. While folic acid is still important during lactation for cell growth and DNA synthesis, the requirement is slightly lower than during pregnancy.
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