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. 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.

A. saturated with clots and mucus B. about the same as after a vaginal birth. C. greater than after a vaginal birth. D. less than after a vaginal birth.

Correct Answer is D

Explanation

A. Saturated with clots and mucus is not typical of lochia in either vaginal or cesarean births unless there is excessive bleeding or other complications. While clots are normal in the early days postpartum, lochia should not be saturated with them in a healthy postpartum recovery.

B. About the same as after a vaginal birth is incorrect because lochia after a cesarean birth tends to be less due to the surgical procedure. The uterus does not expel as much tissue or blood from the vaginal canal as in a vaginal delivery.

C. Greater than after a vaginal birth is incorrect. Although there is a possibility of more bleeding initially from the incision site in a cesarean birth, the amount of lochia is typically less due to the nature of the surgical delivery.

D. Less than after a vaginal birth is correct. After a cesarean birth, the lochia typically is less because the surgical delivery method does not involve the same physical exertion or vaginal tearing that occurs with a vaginal birth. Additionally, the surgical incision prevents some of the natural expulsion of blood and tissue.

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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

A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex?

Correct Answer is B

Explanation

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be:

Correct Answer is D

Explanation

A nurse suspects that a pregnant client may be experiencing a placental abruption based on assessment of which finding? Select all that apply.

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