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

A. Urine output of 50 mL in 4 hr: While urine output should be monitored for signs of magnesium toxicity, a low urine output alone may not be a definitive indication to continue or discontinue the infusion. It is more important to assess for signs of respiratory depression and diminished deep-tendon reflexes, which are more specific indicators of magnesium toxicity.

B. Heart rate of 56/min: While bradycardia can be a sign of magnesium toxicity, it is less specific than respiratory depression and diminished deep-tendon reflexes. Monitoring heart rate is important, but a normal heart rate alone may not be sufficient to determine the safety of continuing the magnesium sulfate infusion.

C. Respiratory rate of 16/min: A normal respiratory rate indicates that the client is not experiencing respiratory depression, a common adverse effect of magnesium sulfate. Therefore, a respiratory rate of 16/min suggests that it is safe for the nurse to continue the infusion. Magnesium sulfate can cause respiratory depression as it acts as a central nervous system depressant, so monitoring respiratory rate is essential to prevent adverse effects.

D. Diminished deep-tendon reflexes: Diminished deep-tendon reflexes are a sign of magnesium toxicity and indicate the need to discontinue or adjust the magnesium sulfate infusion. Therefore, this finding would not suggest that it is safe to continue the infusion.

A. Vertex B. Shoulder C. Mentum D. Breech

Correct Answer is D

Explanation

Answer: D. Breech

Rationale:

A) Vertex:

The vertex presentation is when the baby's head is positioned down in the pelvis, which is not consistent with the RSA (right sacrum anterior) position. RSA indicates a breech position, where the sacrum (lower back of the fetus) is the leading part.

B) Shoulder:

A shoulder presentation occurs when the fetus is lying sideways in the uterus, with a shoulder pointing toward the birth canal. This is not related to the RSA position, which involves the sacrum.

C) Mentum:

The mentum presentation refers to a face presentation where the chin is the leading part. RSA does not indicate a mentum presentation; it indicates the position of the fetus's sacrum, typical of a breech position.

D) Breech:

A breech presentation means the baby's buttocks or feet are positioned to come out first. RSA (right sacrum anterior) indicates that the fetus's sacrum is facing the mother's right anterior side, confirming a breech position.

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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

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Explanation

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Correct Answer is D

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