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 B
Explanation
A. Convection is the loss of heat due to air or fluid movement around the body. While keeping the newborn warm in a draft-free area can help with this, the blanket on the scale primarily addresses heat loss through contact with the cold surface.
B. Conduction occurs when heat is transferred from the baby’s body to a cooler surface that it comes into direct contact with, like the cold scale. By placing a warmed blanket on the scale, the nurse minimizes heat loss due to conduction, ensuring the baby stays warm.
C. Radiation involves heat transfer to cooler objects nearby, but a warmed blanket on the scale does not directly address heat loss through radiation.
D. Evaporation occurs when moisture on the skin evaporates, taking heat away. A warmed blanket would not primarily address evaporation; it’s meant to prevent conduction heat loss.
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.
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