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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pattern of contractions: While the pattern of contractions is an essential aspect of labor, it alone does not confirm whether the client is experiencing true labor. True labor contractions are typically regular, become stronger over time, and occur at shorter intervals.
B. Rupture of the membranes: Rupture of membranes, also known as the water breaking, can occur in both true and false labor. However, it is not the defining factor in distinguishing true labor.
C. Changes in the cervix: Changes in the cervix, such as cervical dilation and effacement, are indicative of true labor. Cervical dilation and effacement occur progressively during true labor, suggesting that the body is preparing for the birth of the baby.
D. Station of the presenting part: The station of the presenting part refers to the level of the fetal head in the pelvis and is an important aspect of labor progress. However, it alone does not confirm whether the client is experiencing true labor.
Correct Answer is A
Explanation
A. Dyspnea: Terbutaline is a β2-adrenergic agonist that is commonly used to inhibit premature labor by relaxing the uterine smooth muscles. Dyspnea can be a sign of pulmonary edema, which is a serious adverse effect of terbutaline. It should be reported to the provider immediately.
B. Headaches: Headaches are a common side effect of terbutaline but are not typically severe enough to warrant immediate reporting unless they are persistent or severe.
C. Tremors: Tremors are a common side effect of terbutaline due to its action as a sympathomimetic drug. While tremors can be uncomfortable for the client, they are not typically indicative of a severe adverse reaction.
D. Nervousness: Nervousness is another common side effect of terbutaline but does not typically require immediate reporting unless it becomes severe or persistent
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