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. Ferrous sulfate is typically prescribed to prevent or treat iron deficiency anemia, which may be needed postpartum if there was significant blood loss during delivery, but it is not related to the care of a perineal laceration.
B. Methylergonovine is a medication used to prevent or treat postpartum hemorrhage by promoting uterine contraction. While it is important for hemorrhage management, it is not used for perineal laceration care.
C. Bromocriptine is used to suppress lactation in clients who are not breastfeeding, but it is not relevant to a fourth-degree laceration.
D. Docusate is a stool softener, which is often prescribed after a fourth-degree perineal laceration. The client needs to avoid straining during bowel movements, as it could put strain on the perineal area and hinder healing. Docusate helps prevent constipation and reduces the risk of further injury to the perineum.

A. Strict intake and output monitoring B. Prepare for delivery of the fetus by cesarean section (C/S) C. Weekly monitoring of coagulation factors D. Complete bed rest for the remainder of the pregnancy

Correct Answer is B

Explanation

A. Strict intake and output monitoring is important for managing any patient with significant blood loss or who is at risk for complications, but it does not directly address the immediate needs of a client with abruptio placentae. The priority is stabilizing the mother and delivering the fetus safely.

B. Prepare for delivery of the fetus by cesarean section (C/S) is correct. Abruptio placentae (placental abruption) is a life-threatening condition where the placenta prematurely detaches from the uterine wall, leading to bleeding and potential fetal distress. Immediate delivery is often required, especially if there is significant bleeding or fetal compromise. A cesarean section is usually the preferred method of delivery in these cases to reduce the risk of maternal and fetal complications.

C. Weekly monitoring of coagulation factors is important for managing coagulopathies that might develop in the presence of placental abruption, but it is not the immediate action required. Immediate delivery is the priority.

D. Complete bed rest for the remainder of the pregnancy may be recommended for certain cases of placental abruption with mild symptoms, but in the presence of moderate vaginal bleeding and significant findings on ultrasound, immediate delivery (typically by C-section) is more urgent.

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

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

The nurse is giving discharge instructions to the client following evacuation of the molar pregnancy. Which of the following information should the nurse ascertain that the client understands?

A nurse is providing care to a postpartum woman. Which of the following behavior by the client would indicate the client is in the Taking in phase?

A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available?

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?

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?

A nurse suspects that a pregnant client may be experiencing a placental abruption based on assessment of which finding? Select all that apply.

The nurse is caring for a client in labor who has refused epidural anesthesia. An order was placed for Stadol 3mg IV Q4h PRN pain. The drug is supplied 2 mg per ml. How much of the medication should the nurse give?

The nurse knows that the occurrence of shoulder dystocia during labor is most likely related to which of the following?