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 B

Explanation

A. 50mg/hr is not the correct unit for volume, it’s the dose in milligrams.
B. 50 mL/hr is the correct volume to administer to achieve the ordered dose of 2g/hr. Determine the concentration of the solution: The supply is 10g in 250mL. This means the concentration is 10g / 250mL, or 0.04g/mL (since 10g = 10,000mg, this is equivalent to 40mg/mL). Convert the ordered dose to match the concentration: The order is for 2g/hr (which is 2,000mg/hr). Calculate the volume to be infused to deliver the desired dose: Dose = Ordered/concentration= 2000/40= 50 mL/hr
C. 5mg/mL refers to the concentration, not the rate of infusion.
D. 5 mL/hr would administer only 200mg/hr, which is much lower than the ordered dose of 2g/hr.

A. Wrap the newborn in a blanket. B. Put a hat on the newborn's head. C. Check the newborn's temperature. D. Dry the newborn thoroughly.

Correct Answer is D

Explanation

A. Wrap the newborn in a blanket helps maintain body heat after the initial drying and stimulation but is not the first priority in thermoregulation.
B. Put a hat on the newborn's head also helps prevent heat loss, particularly from the head, which is a major site of heat loss in newborns. However, this should be done after drying to avoid trapping moisture.
C. Check the newborn's temperature is important but should be done after immediate measures to prevent heat loss have been taken.
D. Dry the newborn thoroughly is the first and most critical step in preventing evaporative heat loss, which is the primary cause of newborn heat loss immediately after birth. Removing wet amniotic fluid from the skin helps stabilize temperature effectively.

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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

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Explanation

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Correct Answer is D

Explanation

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