A nurse is caring for a patient who had a vaginal delivery 12 hours ago.
Where should the nurse expect to find the uterine fundus when palpating the patient’s abdomen?
2 cm above the umbilicus.
One fingerbreadth above the symphysis pubis.
At the level of the umbilicus.
To the right of the umbilicus.
The Correct Answer is A
Choice A rationale
At about 12 hours after delivery, the uterine fundus can be palpated at 1 cm above the umbilicus. This is the correct answer.
Choice B rationale
One fingerbreadth above the symphysis pubis is not where the uterine fundus is expected to be found 12 hours after a vaginal delivery.
Choice C rationale
At the level of the umbilicus is not where the uterine fundus is expected to be found 12 hours after a vaginal delivery.
Choice D rationale
To the right of the umbilicus is not where the uterine fundus is expected to be found 12 hours after a vaginal delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Assessing the amniotic fluid is important after rupture of membranes, but it is not the immediate priority. The nurse should first ensure the safety of the mother and baby.
Choice B rationale
Walking the patient to the bathroom is not the immediate priority. After rupture of membranes, the patient should be assisted back to bed to prevent cord prolapse.
Choice C rationale
Calling and informing the healthcare provider is important, but it is not the first action. The nurse should first assist the patient back to bed and initiate fetal monitoring.
Choice D rationale
Assisting the patient back to bed and initiating fetal monitoring is the correct action. After rupture of membranes, the priority is to assess the fetal heart rate for any signs of distress, such as bradycardia, which could indicate cord prolapse.
Correct Answer is A
Explanation
Choice A rationale
If a client reports feeling “down” and sad, having no energy, and wanting to cry, these could be signs of postpartum depression. It’s crucial to assess whether the client has considered harming her newborn, as this could indicate a severe form of postpartum depression that requires immediate intervention.
Choice B rationale
While anticipating a prescription for an antidepressant might be part of the treatment plan for postpartum depression, it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.
Choice C rationale
Assisting the family to identify prior use of positive coping skills in family crises could be helpful, but it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.
Choice D rationale
Reinforcing postpartum and newborn care discharge teaching is important, but it’s not the immediate priority. The immediate priority is to ensure the safety of both the mother and the newborn.
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