A nurse is collecting data from a client who is 20 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

Positive Homans' sign

Full, firm breasts

Firm fundus at midline

Lochia serosa

Answer and Explanation

The Correct Answer is C

A.   Homans' sign is a test for deep vein thrombosis and is not a normal postpartum finding.
B.   Full, firm breasts typically occur a few days after delivery when milk production begins, not at 20 hours postpartum.
C.   A firm fundus at the midline is an expected finding in the immediate postpartum period, indicating that the uterus is contracting and involuting properly.
D.   Lochia serosa (pinkish-brown discharge) is a normal finding around 3 to 10 days postpartum, but it is not typically present at 20 hours postpartum.

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Correct Answer is C

Explanation

A. The suprapubic area is typically where the uterus can be palpated, but it's not the location for auscultating fetal heart tones at 12 weeks of gestation.

B. The umbilical area is not the optimal location at this stage; the fetal heart tones are generally not audible in this location until the uterus rises higher into the abdomen in later gestation.
C. At 12 weeks of gestation, the fetal heart tones are typically auscultated above the left iliac crest.

D. Below the liver border on the right abdomen is also not correct, as the fetal heart tones are unlikely to be found there at 12 weeks.

A. Place the shoulder harness across the gravid uterus. B. Move the seat as far away as possible from the steering wheel. C. Wear the lap belt high across the abdomen. D. Disable the vehicle's driver-side airbags.

Correct Answer is B

Explanation

A. The shoulder harness should be placed between the breasts and off to the side of the gravid uterus, not directly across it. This helps reduce the risk of injury in the event of a crash.

B. Moving the seat as far away as possible from the steering wheel reduces the risk of injury from the steering wheel or airbag impact while still allowing the client to drive safely.

C. The lap belt should be worn low across the hips and under the abdomen, not high across the abdomen, to protect the growing fetus and prevent harm during sudden deceleration.

D. Airbags should not be disabled as they provide essential protection during a crash. Proper seatbelt use and correct seating position allow airbags to function effectively without posing a risk to the pregnant client.

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A nurse is collecting data from a client who is 20 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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