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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Elevated liver enzymes is a key indicator of HELLP syndrome, which stands for Hemolysis, Elevated Liver enzymes, and Low Platelets. HELLP syndrome is a severe form of preeclampsia and can lead to liver damage. Elevated liver enzymes, such as AST and ALT, are a hallmark of this condition, indicating liver dysfunction.
B. Elevated platelet count would be the opposite of what is expected in HELLP syndrome. In HELLP syndrome, there is typically low platelet count (thrombocytopenia), not an elevated one.
C. Leukocytosis refers to an increased white blood cell count, which can be indicative of an infection or inflammation, but it is not a hallmark of HELLP syndrome. HELLP syndrome primarily involves hemolysis, liver enzyme elevation, and low platelets.
D. Hyperglycemia is not a characteristic finding of HELLP syndrome. While it can occur in some pregnancy-related conditions, it is not specifically associated with HELLP syndrome. This condition is more associated with elevated liver enzymes and low platelets.
Correct Answer is B
Explanation
A. Stepping reflex is elicited by holding the newborn upright with feet touching a flat surface; the baby will make stepping movements.
B. Babinski reflex is correct. This reflex is elicited by stroking the lateral sole of the foot from the heel to the ball of the foot. A positive Babinski response in newborns is dorsiflexion of the big toe and fanning of the other toes — a normal finding up to about 12 months of age.
C. Tonic neck reflex (also called the “fencing” reflex) is seen when the newborn's head is turned to one side — the arm on that side extends while the opposite arm bends.
D. Plantar grasp is elicited by pressing a finger against the sole of the foot near the toes; the newborn will respond by curling the toes downward.
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