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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Jaundice is not typically a primary concern in the case of a ruptured ectopic pregnancy. Jaundice is more associated with liver dysfunction, not hemorrhage or the acute events following an ectopic pregnancy rupture.
B. Depression is an emotional response that could occur after a traumatic event like an ectopic pregnancy, but it is not the priority in an acute situation where physical signs of a life-threatening condition like hemorrhage need immediate attention.
C. Edema may be present in a variety of conditions but is not as urgent or immediately life-threatening as hemorrhage in the case of a ruptured ectopic pregnancy.
D. Hemorrhage is the priority concern in a suspected ruptured ectopic pregnancy. A ruptured ectopic pregnancy can lead to significant internal bleeding, which can cause hypovolemic shock and be life-threatening. Immediate attention to monitoring for signs of hemorrhage (such as hypotension, tachycardia, dizziness, and abdominal pain) is crucial to ensure the client's safety.
Correct Answer is D
Explanation
A. A score of 7 would be given if the infant’s heart rate was 100, but with less than optimal responses for color, muscle tone, and respiratory effort. However, this baby demonstrates strong responses in all categories.
B. A score of 8would indicate that the baby has no signs of cyanosis and perfect responses in all categories, but since the infant has blue hands, it scores slightly lower (1 point less for color).
C. A score of 5 would indicate more significant distress, with poor color, respiratory effort, and muscle tone. This infant is showing good signs of adaptation.
D. The Apgar score is calculated based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The infant in the scenario has:Heart rate of 100 (score 2)Pink body and blue hands (score 1 for color—because the baby is not fully pink, indicating some cyanosis in the extremities)Active motion (score 2 for muscle tone)Strong lusty cry (score 2 for reflex irritability/responsiveness to stimuli)
Good respirations (score 2)Adding these scores (2 + 1 + 2 + 2 + 2), the total is 9.
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