A nurse is caring for a client who is 12 hr 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 soft, 2 cm above the umbilicus

Fundus firm, at the level of the umbilicus

Fundus present, to the left of the umbilicus

Answer and Explanation

The Correct Answer is C

C) Fundus firm, at the level of the umbilicus:
Twelve hours postpartum, the fundus should be firm, indicating ongoing uterine contraction, and it should be at the level of the umbilicus. This position and consistency indicate that the uterus is involuting properly, and bleeding risk is reduced.

A) Fundus soft, 1 cm to the right of the umbilicus:
A soft fundus located 1 cm to the right of the umbilicus suggests that the uterus is not contracting adequately and may be at risk for postpartum hemorrhage. This finding is not expected 12 hours postpartum.

B) Fundus soft, 2 cm above the umbilicus:
A soft fundus located 2 cm above the umbilicus suggests that the uterus is not contracting adequately and may be at risk for postpartum hemorrhage. This finding is not expected 12 hours postpartum.

D) Fundus present, to the left of the umbilicus:
The location "to the left of the umbilicus" is not a normal position for the fundus postpartum. The fundus should be at or below the level of the umbilicus to indicate proper involution.

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Correct Answer is C

Explanation

C) Position the client on her side:
Late decelerations indicate uteroplacental insufficiency, which could compromise fetal oxygenation. The priority nursing action is to reposition the client on her side to alleviate pressure on the vena cava and improve placental blood flow. Side-lying position, particularly the left lateral position, can enhance placental perfusion and alleviate pressure on the vena cava, thus improving fetal oxygenation.

A) Elevate the client's legs:
Elevating the client's legs is not the priority action for addressing late decelerations. While it might be beneficial in some situations, the immediate priority is to reposition the client to improve uteroplacental perfusion.

B) Increase the infusion rate of the IV fluid:
Increasing the infusion rate of IV fluid is not the priority action for addressing late decelerations. While ensuring adequate hydration is important during labor, the priority is to reposition the client to improve uteroplacental perfusion.

D) Administer oxygen via face mask:
Administering oxygen via face mask is an appropriate intervention for fetal distress; however, repositioning the client to alleviate late decelerations takes precedence. If late decelerations persist after repositioning, then providing oxygen therapy would be the next appropriate action.

Correct Answer is ["732"]

Explanation

To calculate the total intake, we need to convert all measurements to the same unit, in this case, milliliters (mL).

1 ounce (oz) is approximately equal to 29.5735 mL.

Also, it’s important to note that when ice chips melt, they become about half their volume in water. So, 100 mL of ice chips would become about 50 mL of wate

Let’s calculate:

Juice: 4 oz * 29.5735 = 118.294 mL

Tea: 6 oz * 29.5735 = 177.441 mL

Ice chips: 100 mL * 0.5 = 50 mL

IV bolus: 150 mL

Broth: 8 oz * 29.5735 = 236.588 mL

Adding all these together:

118.294 mL (juice) + 177.441 mL (tea) + 50 mL (ice chips) + 150 mL (IV bolus) + 236.588 mL (broth) = 732.323 mL

So, the nurse should record 732 mL of intake on the client’s record (rounded to the nearest whole number).

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

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

Correct Answer is C

Explanation

A nurse is completing an 8-hr 1&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

Correct Answer is ["732"]

Explanation

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