A nurse is collecting data from a client who is 12 hours postpartum following a spontaneous vaginal delivery.
The nurse should expect to find the uterine fundus at which of the following positions on the client’s abdomen?

At 1 cm above the umbilicus.

One fingerbreadth above the symphysis pubis.

To the right of the umbilicus.

Three fingerbreadths above the umbilicus.

Answer and Explanation

The Correct Answer is A

Choice A rationale

At 1 cm above the umbilicus is the expected position of the uterine fundus 12 hours postpartum. After delivery, the fundus is typically at the level of the umbilicus and then descends approximately 1 cm per day. At 12 hours postpartum, it is normal for the fundus to be slightly above the umbilicus.

Choice B rationale

One fingerbreadth above the symphysis pubis is not the expected position of the fundus 12 hours postpartum. This position is more typical several days postpartum as the uterus continues to involute and return to its pre-pregnancy size.

Choice C rationale

To the right of the umbilicus is not a normal finding and may indicate a full bladder, which can displace the uterus. The nurse should assist the client to void and then reassess the fundal position.

Choice D rationale

Three fingerbreadths above the umbilicus is not expected 12 hours postpartum. This position may indicate uterine atony or subinvolution, which requires further assessment and intervention.

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Correct Answer is C

Explanation

Choice A rationale

Inserting a urinary catheter is not the first action to take when the fundus is displaced to the right of midline. The displacement is often due to a full bladder, and the client should be encouraged to void first.

Choice B rationale

Massaging the fundus is appropriate if the uterus is boggy, but in this case, the fundus is firm. The displacement is likely due to a full bladder.

Choice C rationale

Having the client urinate is the correct action. A full bladder can displace the uterus and prevent it from contracting properly, which can lead to postpartum hemorrhage.

Choice D rationale

Administering analgesia is not relevant to the issue of a displaced fundus. The priority is to address the cause of the displacement, which is likely a full bladder.

A. An indication of a cervical or perineal laceration. B. Abnormally excessive lochia rubra flow. C. A normal postural discharge of lochia. D. Evidence of a possible vaginal hematoma.

Correct Answer is C

Explanation

Choice A rationale

A cervical or perineal laceration would typically result in continuous bleeding rather than a gush that stops. The uterus would also not be firm and midline if there were a significant laceration.

Choice B rationale

Abnormally excessive lochia rubra flow would be continuous and not stop after a gush. The uterus being firm and midline indicates that the bleeding is not excessive.

Choice C rationale

A normal postural discharge of lochia occurs when pooled blood in the vagina is expelled upon standing or changing position. This is common and expected in the postpartum period.

Choice D rationale

A vaginal hematoma would present with localized pain and swelling, and the bleeding would not stop suddenly. The uterus being firm and midline also indicates that a hematoma is unlikely.

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A nurse is collecting data from a client who is 12 hours postpartum following a spontaneous vaginal delivery.The nurse should expect to find the uterine fundus at which of the following positions on the client’s abdomen?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 3 hr postpartum.The nurse notes that the client’s fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops.On data collection, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus.Which of the following findings should the nurse interpret this data as being?

Correct Answer is C

Explanation

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A nurse is collecting data from a client who is 12 hours postpartum following a spontaneous vaginal delivery.
The nurse should expect to find the uterine fundus at which of the following positions on the client’s abdomen?