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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason:
Fetal position is persistent occiput posterior is correct, as this position can cause difficult, prolonged labor and severe backache. The occiput posterior position means that the back of the fetal head is facing the maternal sacrum, which can result in poor alignment and descent, increased pressure on the maternal sacrum and nerves, and increased risk of perineal trauma. The nurse should encourage the client to change positions frequently, use pelvic rocking exercises, apply counterpressure to the sacrum, and administer analgesics as needed.

Choice B reason:
Fetal attitude is in general ﬂexion is incorrect, as this attitude can facilitate normal labor and delivery. The fetal attitude refers to the degree of ﬂexion or extension of the fetal head and limbs in relation to the fetal trunk. General ﬂexion means that the fetal head is ﬂexed on the chest, the arms are crossed over the chest, and the legs are ﬂexed at the knees. This attitude allows the smallest diameter of the fetal head to pass through the birth canal.

Choice C reason:
Fetal lie is longitudinal is incorrect, as this lie can facilitate normal labor and delivery. The fetal lie refers to the relationship between the long axis of the fetus and the long axis of the mother. Longitudinal lie means that both axes are parallel, which allows for either a vertex (head-first) or a breech (butocks-first) presentation.

Choice D reason:
Maternal pelvis is gynecoid is incorrect, as this pelvis can facilitate normal labor and delivery. The maternal pelvis refers to the shape and size of the bony pelvis that aﬀects the passage of the fetus. Gynecoid pelvis is the most common and favorable type for vaginal birth, as it has a rounded inlet, a wide pubic arch, and adequate outlet dimensions.

A. Urinary output 2,000 mL/12 hr B. Temperature 100.4 F for two days C. Chills shortly following delivery D. Fundus at umbilicus level

Correct Answer is B

Explanation

Choice A reason:

A urinary output of 2,000 mL/12 hr is normal for a postpartum client, as the body eliminates excess ﬂuid accumulated during pregnancy.

Choice B reason:

A temperature of 100.4 F for two days indicates a possible infection, such as endometritis or mastitis, and requires further evaluation and treatment.

Choice C reason:

Chills shortly following delivery are common and benign and are caused by hormonal changes and ﬂuid shifts.

Choice D reason:

A fundus at the umbilicus level is expected for a postpartum client and indicates that the uterus is involuting properly.

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A nurse is collecting data from a client who is 24 hr postpartum. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is in labor. The client's labor is difficult and prolonged and she reports a severe backache. Which of the following factors is a contributing cause of difficult, prolonged labor?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is 24 hr postpartum. Which of the following findings should the nurse expect?

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