A nurse is caring for a client who is 12 hours postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

Fundus soft, 1 cm to the right of the umbilicus.

Fundus firm, at the level of the umbilicus.

Fundus soft, 2 cm above the umbilicus.

Fundus present, to the left of the umbilicus.

Answer and Explanation

The Correct Answer is B

Choice a reason:
The fundus being soft and to the right of the umbilicus could indicate that the bladder is full and displacing the uterus. This is not an expected finding and would require the nurse to encourage the client to empty her bladder to help the uterus contract and return to its normal position.

Choice b reason:
The expected finding for a client who is 12 hours postpartum is for the fundus to be firm and at the level of the umbilicus. A firm fundus indicates good uterine tone and that the uterus is contracting as it should to return to its pre-pregnancy size. This helps to prevent excessive bleeding and promotes recovery.

Choice c reason:
A fundus that is soft and 2 cm above the umbilicus is not an expected finding at 12 hours postpartum. This could suggest that the uterus is not contracting properly, which could lead to postpartum hemorrhage. The nurse would need to assess further and possibly provide interventions such as fundal massage or medication to encourage uterine contractions.

Choice d reason:
The fundus being present to the left of the umbilicus may indicate that the uterus is not contracting symmetrically or that there is a full bladder displacing the uterus. This finding would prompt the nurse to assess for bladder distention and encourage the client to void to help the uterus contract properly.

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Correct Answer is D

Explanation

Choice A reason:
Nausea can be a common side effect of many medications and does not necessarily indicate toxicity. While it can be uncomfortable for the patient, nausea alone, without other symptoms, is not typically a sign of magnesium sulfate toxicity.
Choice B reason:
Drowsiness is another side effect that can occur with various medications and medical conditions. It may be a symptom of magnesium sulfate toxicity, especially if it is severe or combined with other symptoms, but on its own, it is not a definitive indicator of toxicity.
Choice C reason:
Facial flushing can be a reaction to medication, including magnesium sulfate, and may occur even at therapeutic levels. It is not usually a sign of toxicity unless accompanied by more serious symptoms.
Choice D reason:
Respiratory depression is a serious and potentially life-threatening condition that can indicate magnesium sulfate toxicity. It is characterized by a decrease in the ability to breathe and a drop in oxygen levels. This is a critical finding that requires immediate medical attention and intervention.

A. Increasing abdominal pain with a nonrelaxed uterus. B. Abdominal pain with scant red vaginal bleeding. C. Painless red vaginal bleeding. D. Intermittent abdominal pain following the passage of bloody mucus.

Correct Answer is C

Explanation

Choice a reason:
Increasing abdominal pain with a nonrelaxed uterus is not typically indicative of placenta previa. This symptom could suggest other complications such as uterine rupture or placental abruption, which are serious conditions requiring immediate medical attention.

Choice b reason:
Abdominal pain with scant red vaginal bleeding is also not a classic sign of placenta previa. While vaginal bleeding can occur in placenta previa, it is usually not associated with abdominal pain. Pain accompanied by bleeding is more suggestive of other obstetric emergencies.

Choice c reason:
Painless red vaginal bleeding is a hallmark sign of placenta previa. In placenta previa, the placenta covers the cervical os either partially or completely, leading to bleeding when the lower part of the uterus stretches and thins as part of the preparation for labor. This bleeding is typically sudden and painless and can range from light to heavy.

Choice d reason:
Intermittent abdominal pain following the passage of bloody mucus is not characteristic of placenta previa. This symptom could be associated with the normal process of losing the mucus plug as labor approaches or could indicate other conditions but is not specific to placenta previa.

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A nurse is caring for a client who is 12 hours postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity from magnesium sulfate therapy and report to the provider?

Correct Answer is D

Explanation

A nurse is caring for a client who is at 36 weeks of gestation and has a suspected placenta previa. Which of the following findings support this diagnosis?

Correct Answer is C

Explanation

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?

A nurse is caring for a newborn delivered by vaginal birth with vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?

A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?

A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 minutes. The nurse suspects placenta previa. Which of the following is an appropriate nursing action?

A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse expect? (Select all that apply)

A nurse is teaching a client who is at 23 weeks of gestation and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client?

A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?