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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
While vaginal bleeding can be associated with ectopic pregnancy, it is not typically characterized by a large amount. The bleeding is often described as spotting or light bleeding. A large amount of vaginal bleeding is more indicative of other conditions, such as a miscarriage or placental issues.
Choice B reason:
Unilateral, cramp-like abdominal pain is one of the hallmark signs of an ectopic pregnancy. This pain is usually felt on one side of the abdomen and can vary from mild to severe. It occurs due to the embryo implanting outside the uterus, most commonly in one of the fallopian tubes, which can cause irritation and discomfort as it grows.
Choice C reason:
Uterine enlargement greater than expected for gestational age is not a symptom of ectopic pregnancy. In fact, the uterus may not enlarge as much as expected because the embryo is not growing inside it. Ectopic pregnancies are often associated with a smaller-than-expected uterus for the gestational age.
Choice D reason:
Severe nausea and vomiting are not specific to ectopic pregnancy and can occur with any pregnancy. However, if these symptoms are accompanied by other signs of ectopic pregnancy, such as abdominal pain and vaginal bleeding, they may support the diagnosis.
Correct Answer is B
Explanation
Choice A reason:
The absence of vitamin K in newborns is a concern as it is essential for blood clotting. Newborns are at risk of vitamin K deficiency bleeding (VKDB), which can lead to serious bleeding issues but not typically jaundice. VKDB is preventable with a vitamin K injection at birth.
Choice B reason:
Physiologic jaundice is common in newborns and usually appears between the second and fourth day after birth. It occurs due to the baby's liver not being mature enough to get rid of bilirubin in the bloodstream. This type of jaundice is generally harmless and resolves on its own within two weeks.
Choice C reason:
Maternal cocaine abuse can have numerous adverse effects on a newborn, including premature birth and withdrawal symptoms, but it does not directly cause jaundice. The symptoms of cocaine exposure in newborns can include tremors, muscle spasms, and difficulty feeding.
Choice D reason:
Blood group incompatibility, such as Rh disease or ABO incompatibility, can lead to hemolytic disease of the newborn (HDN), which can cause jaundice. This occurs when the mother's antibodies attack the baby's red blood cells, leading to increased bilirubin levels.
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