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. "I need to call my doctor if my temperature increases." This is an appropriate and accurate statement. An elevated temperature could be a sign of infection, which is a risk for women with preterm prelabor rupture of membranes (PPROM). The woman should contact her healthcare provider if her temperature rises, as infection can lead to complications.

B. "I can shower, but I shouldn't take a tub bath." This is also correct. After PPROM, the woman is typically allowed to shower to maintain personal hygiene, but taking a tub bath can increase the risk of infection by allowing bacteria to enter the vagina.

C. "I need to keep a close eye on how active my baby is each day." This is a correct and helpful statement. Monitoring fetal movement is important for assessing the baby's well-being. Decreased fetal movement could indicate a potential problem, and the woman should contact her provider if she notices reduced activity.

D. "It's okay for my husband and me to have sexual intercourse." This statement indicates a need for additional teaching. Sexual intercourse is typically not recommended after PPROM because it could increase the risk of infection, especially if the membranes are ruptured. The woman should avoid sexual activity until advised otherwise by her healthcare provider.

A. difficulty in arousing B. deep tendons reflexes 2+ C. urinary output of 20 mL per hour D. respiratory rate of 10 breaths/minute

Correct Answer is B

Explanation

A. Difficulty in arousing suggests central nervous system depression, which can be a sign of magnesium toxicity. This is not a therapeutic effect and requires immediate assessment and possible discontinuation of the medication.
B. Deep tendon reflexes 2+ indicates normal neuromuscular function, which is consistent with therapeutic levels of magnesium sulfate. Loss of deep tendon reflexes is often the first sign of magnesium toxicity, so their presence at a normal level is reassuring.
C. Urinary output of 20 mL per hour is below the expected minimum (typically 30 mL/hour) and may suggest impaired renal function, which increases the risk of magnesium accumulation and toxicity.
D. Respiratory rate of 10 breaths/minute is lower than normal and may indicate respiratory depression, a serious sign of magnesium toxicity. A rate below 12 breaths/minute is concerning and not consistent with therapeutic dosing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a pregnant woman with preterm prelabor rupture of membranes about caring for herself after she is discharged home (which is to occur later this day). Which statement by the woman indicates a need for additional teaching?

Correct Answer is D

Explanation

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?

Correct Answer is B

Explanation

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed?

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take?

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?

The new mother asks the nurse about the presence of a small blood-tinged area on her daughter's diaper. Which response by the nurse would be most accurate?

The nurse is caring for a client receiving Magnesium Sulphate. The loading dose has already been given and the maintenance dose order reads 1g/hr. The drug is supplied 20g/500ml Solve the maintenance dose to be given in ml/hr

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A client with severe hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care?

A nurse is teaching a new mother about breastfeeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down?