A nurse is collecting data from a client who is 8 hr postpartum. Where should the nurse expect to find the fundus?

At a non-palpable depth

At the umbilicus

2 cm below the umbilicus

Just above the symphysis pubis

Answer and Explanation

The Correct Answer is B

A. At a non-palpable depth – Incorrect; the fundus is still palpable in the immediate postpartum period.
B. At the umbilicus – Correct; at 8 hours postpartum, the fundus is typically at the level of the umbilicus.
C. 2 cm below the umbilicus – Incorrect; the fundus begins to descend around 24 hours postpartum.
D. Just above the symphysis pubis – Incorrect; this occurs around day 10 postpartum.

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Correct Answer is ["A","B"]

Explanation

A. Methicillin-resistant Staphylococcus aureus (MRSA) – Correct; requires contact precautions due to the risk of direct and indirect transmission.

B. Vancomycin-resistant Enterococcus (VRE) – Correct; requires contact precautions as it spreads through contaminated surfaces and hands.

C. Pertussis – Incorrect; pertussis is transmitted via droplets, so droplet precautions are needed.

D. Influenza – Incorrect; influenza spreads via droplets, requiring droplet precautions.

E. Group A Streptococcus B-hemolytic – Incorrect; requires droplet precautions, unless skin infections are present, which would then require contact precautions.

A. Feel for a full bladder. B. Request the provider perform a vaginal examination. C. Check the client's fundus. D. Measure the client's vital signs.

Correct Answer is C

Explanation

A. Feel for a full bladder. – Incorrect; a full bladder can contribute to postpartum bleeding, but checking fundal firmness should be prioritized first.

B. Request the provider perform a vaginal examination. – Incorrect; the nurse should assess the fundus and attempt interventions first before calling the provider.

C. Check the client’s fundus. – Correct; the priority action is to assess the fundus for firmness, as a boggy uterus is the most common cause of postpartum hemorrhage.

D. Measure the client’s vital signs. – Incorrect; while vital signs are important, assessing fundal tone and initiating interventions come first.

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A nurse is collecting data from a client who is 8 hr postpartum. Where should the nurse expect to find the fundus?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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