A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected?

two fingerbreadths above the umbilicus

two fingerbreadths below the umbilicus

at the level of the umbilicus

four fingerbreadths below the umbilicus

Answer and Explanation

The Correct Answer is C

A. Two fingerbreadths above the umbilicus would be abnormal and may indicate uterine distension due to retained placental fragments or a full bladder, especially this long after delivery.

B. Two fingerbreadths below the umbilicus is typically expected 24 hours or more after delivery, not at 12 hours postpartum.

C. At the level of the umbilicus is normal and expected at about 12 hours postpartum. After delivery, the uterus rises slightly and is generally found at or near the umbilicus before it begins to descend (involute) by about 1 fingerbreadth per day.

D. Four fingerbreadths below the umbilicus would be expected several days postpartum, not within the first 12 hours.

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Correct Answer is D

Explanation

A. Requests time to talk on the phone is more reflective of the "taking in" phase, where the mother is focused on herself and her own needs, such as resting and reflecting on the birth experience. This phase typically involves less engagement with the baby and more focus on recovery.

B. Hesitates to initiate contact with the newborn is characteristic of the "taking in" phase as well. During this phase, the mother may still be adjusting and may not yet feel confident in caring for her baby, often focusing more on her own recovery.

C. Allows staff to perform most of the infant's care is also more indicative of the "taking in" phase. During this phase, the mother is still learning and may feel less confident, often relying on others to care for the newborn.

D. Questions the nurse about frequency of feeding for the newborn is a behavior typically seen in the "taking hold" phase. During this phase, the mother becomes more active in caring for the baby, taking responsibility for its care, and showing interest in learning about the baby’s needs (such as feeding). This phase involves a shift toward becoming more independent and engaged in infant care.

A. cephalhematoma. B. molding C. microcephaly D. caput succedaneum

Correct Answer is D

Explanation

A. Cephalhematoma refers to a collection of blood between the baby's skull and the periosteum (the membrane covering the bone), which does not cross the suture lines. It typically occurs after a traumatic delivery, but it is not diffuse edema like caput succedaneum.

B. Molding refers to the shaping of the baby’s head to fit through the birth canal during delivery. It involves temporary changes to the skull bones (such as overlapping sutures) but does not involve edema or soft tissue swelling.

C. Microcephaly is a condition where a newborn's head is abnormally small, usually due to developmental issues, and it has nothing to do with edema or swelling of the soft tissues.

D. Caput succedaneum is the correct term for diffuse edema of the newborn’s scalp that crosses the suture lines. It is caused by the pressure during delivery as the baby's head moves through the birth canal, and it typically resolves within a few days after birth.

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A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which observed behavior would indicate to the nurse that a post-partum client had progressed to the "taking hold" phase?

Correct Answer is D

Explanation

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:

Correct Answer is D

Explanation

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