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. Birth trauma typically refers to physical injuries sustained during delivery, such as bruising or fractures. Bluish markings across the lower back are not indicative of birth trauma.
B. Stork bites are reddish or pinkish marks, usually found on the nape of the neck, eyelids, or forehead. They are vascular birthmarks and are not bluish in color.
C. Milia refers to small white cysts found on a newborn's face, usually on the nose, chin, or forehead, caused by blocked sebaceous glands. It is not associated with bluish markings.
D. Mongolian spots are bluish or purplish birthmarks commonly found on the lower back or buttocks of infants, especially those with darker skin. These are normal and typically fade over time.

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

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as:

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 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?

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

A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem?

An ultrasound is performed on a client at term who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on this finding, what would be the next action?

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?

The nurse is caring for a client, which symptom indicates severity of pregnancy- induced hypertension and signs of HELLP syndrome?

A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate?

Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as: