A nurse is collecting data from a client who is 24 hr postpartum. Which of the following findings should the nurse expect?
Fundus soft, 2 fingerbreadths below the umbilicus
Fundus firm, 1 fingerbreadth below the umbilicus
Fundus firm, 4 fingerbreadths above the umbilicus
Fundus soft, to the right of the umbilicus
The Correct Answer is B
Choice A reason: Fundus soft, 2 fingerbreadths below the umbilicus is incorrect, as this finding indicates uterine atony and subinvolution. The fundus is the upper part of the uterus that can be palpated through the abdomen after birth. The fundus should be firm and midline to indicate adequate uterine contraction and involution. A soft or boggy fundus can increase the risk of hemorrhage and infection.
Choice B reason: Fundus firm, 1 fingerbreadth below the umbilicus is correct, as this finding indicates normal uterine contraction and involution. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one fingerbreadth per day. A firm and midline fundus can prevent excessive bleeding and promote healing.
Choice C reason: Fundus firm, 4 fingerbreadths above the umbilicus is incorrect, as this finding indicates a higher than expected fundal height for a client who is 24 hr postpartum. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one fingerbreadth per day. A high fundal height can indicate uterine atony, retained placental fragments, or bladder distension.
Choice D reason: Fundus soft, to the right of the umbilicus is incorrect, as this finding indicates uterine atony and bladder distension. The fundus should be firm and midline to indicate adequate uterine contraction and involution. A deviated fundus can indicate bladder distension, which can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Apply warm, moist soaks to the client's lower legs is incorrect, as this action is not effective for preventing thrombophlebitis. Warm, moist soaks can provide comfort and reduce inflammation, but they do not improve blood circulation or prevent clot formation.
Choice B reason: Have the client ambulate frequently in the hallway is correct, as this action can prevent thrombophlebitis by improving venous return and preventing stasis. The nurse should encourage and assist the client to ambulate early and frequently after a cesarean birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide support as needed.
Choice C reason: Keep the client on bed rest is incorrect, as this action can increase the risk of thrombophlebitis by reducing blood flow and promoting stasis. Bed rest can also delay wound healing and increase the risk of infection and deconditioning. The nurse should avoid keeping the client on bed rest unless absolutely necessary.
Choice D reason: Place pillows under the client's knees while she is resting in bed is incorrect, as this action can impair blood circulation and increase the risk of thrombophlebitis. Placing pillows under the knees can cause pressure on the popliteal veins and reduce venous return. The nurse should advise the client to avoid crossing their legs or placing pillows under their knees while resting in bed.
Correct Answer is D
Explanation
Choice A reason:
Given too soon, epidural anesthesia can cause fetal depression is incorrect, as epidural anesthesia does not cross the placenta and does not affect the fetal status.
Choice B reason:
Given too soon, epidural anesthesia will delay rupture of fetal membranes is incorrect, as epidural anesthesia does not interfere with the rupture of membranes. The rupture of membranes depends on the cervical dilation and effacement, the position of the presenting part, and the strength of contractions.
Choice C reason:
Given too soon, epidural anesthesia can cause maternal hypertension is incorrect, as epidural anesthesia can cause maternal hypotension due to vasodilation and decreased venous return. The nurse should monitor the client's blood pressure and administer fluids and vasopressors as needed.
Choice D reason:
Given too soon, epidural anesthesia can prolong labor is correct, as epidural anesthesia can decrease the strength and frequency of contractions and reduce the urge to push. The nurse should ensure that the client has a good labor patern before administering epidural anesthesia and monitor the progress of labor afterwards.
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