A nurse is caring for a client who experienced a vaginal delivery 48 hours ago.
When assessing the client's uterus, where should the nurse expect to palpate the uterine fundus at this time?
To the right of the umbilicus.
1 centimeter above the symphysis pubis.
2 centimeters above the umbilicus.
At the level of the umbilicus.
The Correct Answer is D
Choice A rationale
Palpating the fundus to the right of the umbilicus suggests a deviation, which is most often caused by a full bladder pushing the uterus out of its midline position. While the uterus is firm at 48 hours postpartum, its normal location should still be midline, not deviated. A distended bladder interferes with uterine contraction and involution, increasing the risk of postpartum hemorrhage.
Choice B rationale
The fundus is typically no longer palpable at the symphysis pubis until about 9 to 10 days postpartum as the process of involution continues and the uterus descends back into the true pelvis. At 48 hours (2 days) postpartum, the fundus should be much higher, approximately at or near the level of the umbilicus, having descended about 1 to 2 cm per day since delivery.
Choice C rationale
The fundus is located at the umbilicus immediately after delivery and descends at a rate of approximately 1 cm (or one fingerbreadth) per day. Therefore, two centimeters above the umbilicus would be the expected finding immediately after birth or possibly in the first 12 hours postpartum, not at the 48-hour mark, indicating a slower than expected involution.
Choice D rationale
The normal rate of uterine involution is for the fundus to descend about 1 to 2 cm per day following delivery. Since the fundus is typically at the umbilicus (U) or 1 to 2 cm below the umbilicus (U-1 or U-2) within 12 to 24 hours postpartum, finding it at the level of the umbilicus at 48 hours is a common and acceptable finding, representing normal progression. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Assisting the client to the bathroom is a comfort and hygiene measure that is secondary to ensuring fetal well-being, especially after rupture of membranes. Although important, the highest priority action immediately following SROM is assessing for potential complications like umbilical cord prolapse, which directly impacts fetal oxygenation and survival.
Choice B rationale
Documenting the uterine contraction pattern provides crucial information about the labor progress and uterine activity. However, assessing the immediate status of the fetus after rupture of membranes takes precedence, as the sudden loss of fluid can sometimes lead to cord compression or prolapse, posing an acute risk to the fetus.
Choice C rationale
While clear amniotic fluid suggests a low risk for meconium aspiration, preparing for delivery is premature if labor is still in the early stages and the cervical status has not been confirmed. The immediate priority is assessing the fetal heart rate tracing to rule out a potential emergency like cord prolapse or acute fetal compromise.
Choice D rationale
Evaluating the fetal heart tracing is the priority nursing action immediately following spontaneous rupture of membranes. This is performed to assess for abrupt changes in the fetal heart rate, specifically looking for decelerations that could indicate umbilical cord compression or, critically, a loop of cord prolapsing into the vagina following the gush of amniotic fluid.
Correct Answer is A
Explanation
Choice A rationale
Lactogenesis II, also known as secretory activation, is the stage where copious milk production begins, typically between 30 and 72 hours postpartum. This is triggered by the rapid drop in the circulating levels of progesterone and estrogen, which occurs immediately following the delivery and expulsion of the placenta, removing the inhibitory effect of these hormones on prolactin's action.
Choice B rationale
Lactogenesis I, known as secretory differentiation, begins around 16 weeks of gestation and continues in the immediate postpartum period. During this stage, the breasts are producing colostrum. Milk production is inhibited until the delivery of the placenta, making the delivery of the fetus insufficient as a solitary trigger for the transition to mature milk.
Choice C rationale
Lactogenesis III, also referred to as galactopoiesis, is the stage of established milk production, which relies on autocrine (local, supply-and-demand) control. Milk stasis, or milk remaining in the ducts, actually inhibits milk production through a feedback inhibitor of lactation (FIL), contradicting the expected function of this stage.
Choice D rationale
The trigger for the transition to mature milk (Lactogenesis II) is the hormonal shift after placental expulsion, specifically the rapid fall in progesterone, which removes the inhibitory block on alveolar cells. Uterine involution is a slower, separate process that is primarily dependent on oxytocin release, and it does not directly trigger the onset of copious milk production.
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