A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal?

two fingerbreadths above the umbilicus

two fingerbreadths below the umbilicus

four fingerbreadths below the umbilicus

at the level of the umbilicus

Answer and Explanation

The Correct Answer is B

A. Two fingerbreadths above the umbilicus would not be a normal finding 48 hours postpartum. By this time, the uterus should be well on its way to returning to its pre-pregnancy size and position, typically about 1 to 2 fingerbreadths below the umbilicus.

B. Two fingerbreadths below the umbilicus is the expected finding 48 hours postpartum. After birth, the uterus begins to shrink (involution) and descend into the pelvic cavity. By 48 hours, the fundus is usually 1–2 fingerbreadths below the umbilicus.

C. Four fingerbreadths below the umbilicus would be more typical of a finding several days later, after the process of involution continues. This could be a sign that the uterus is shrinking at the expected rate.

D. At the level of the umbilicus is typically expected within the first 24 hours after delivery, but by 48 hours postpartum, the fundus should have descended slightly below the level of the umbilicus.

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Correct Answer is D

Explanation

A. To enhance the clearing of the newborn's respiratory passages is not the primary reason for putting the newborn to the breast immediately. While early skin-to-skin contact and breastfeeding are beneficial, the clearing of respiratory passages is more directly related to the initial care the baby receives (such as suctioning if necessary), not breastfeeding.

B. To aid in maturing the newborn's sucking reflex is not the main reason for immediate breastfeeding. The sucking reflex is typically well-established in most newborns by the time of birth, and breastfeeding can help reinforce it. However, the reflex is present and functional even if the baby is not immediately breastfeeding.

C. To encourage the development of maternal antibodies is important in the longer term. Breastfeeding does provide immunological benefits to the baby (like colostrum), but the immediate reason for putting the baby to the breast is more about bonding and initiating breastfeeding.

D. To facilitate maternal-infant bonding is the primary reason for encouraging early breastfeeding. Skin-to-skin contact and breastfeeding immediately after birth promote emotional bonding between the mother and baby, which is beneficial for both. It also promotes the release of oxytocin in the mother, which supports uterine involution and maternal well-being.

A. 2 cm below the umbilicus B. cannot be palpated C. 6 cm below the umbilicus D. halfway below the umbilicus

Correct Answer is A

Explanation

A. By 12 days postpartum, the fundus should be about 2 cm below the umbilicus, as the uterus is returning to its pre-pregnancy size. This is a normal finding at this stage of postpartum recovery.
B. At 12 days postpartum, the fundus should still be palpable, though it will be much lower than in the immediate postpartum period.
C. This is too low for 12 days postpartum. The fundus should not descend this far yet.
D. Halfway below the umbilicus would be expected around 7-10 days postpartum, but by 12 days, the fundus should be about 2 cm below the umbilicus, indicating more involution.

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A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus?

Correct Answer is A

Explanation

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