During a routine postpartum assessment following a normal vaginal delivery, the nurse notes the fundus is firm, but the level has changed from U-1 to U+1 and deviated to the left. Which action would be appropriate before continuing the assessment?

Request the client to empty her bladder

Follow PRN order to insert a straight urinary catheterization

Start an IV and add 20 units Pitocin

Massage fundus until it descends below the level on umbilicus.

Answer and Explanation

The Correct Answer is A

A. Request the client to empty her bladder is the correct action. A fundus that is firm but deviated to the left and higher than expected (U+1) suggests that the bladder is full. A full bladder can displace the uterus, causing it to become misaligned and elevated. Asking the client to empty her bladder is often the first step to address this situation before proceeding with further assessment or intervention.

B. Follow PRN order to insert a straight urinary catheterization might be appropriate if the client is unable to empty her bladder voluntarily, but it is typically a last resort. Before resorting to catheterization, encourage the client to try to void first.

C. Start an IV and add 20 units Pitocin would be indicated if there were signs of uterine atony or hemorrhage. However, in this case, the issue seems related to bladder distention rather than uterine atony, so starting Pitocin is not the appropriate immediate response.

D. Massage fundus until it descends below the level of the umbilicus would be done if the fundus were boggy or soft, indicating uterine atony. However, in this case, the fundus is described as firm, so massaging is not necessary. The priority is addressing the bladder distention.

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Correct Answer is B

Explanation

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.

A. nonshivering thermogenesis B. cold stress C. convection D. bilirubin conjugation

Correct Answer is A

Explanation

A. Nonshivering thermogenesis is the primary method of heat production in newborns. Unlike adults, newborns do not generate heat through shivering. Instead, they rely on the metabolism of brown adipose tissue (brown fat) to produce heat. This process is triggered by exposure to cold and helps maintain body temperature.

B. Cold stress is a condition, not a heat production mechanism. It occurs when the newborn is exposed to cold temperatures, leading to increased oxygen and energy demands as the body attempts to produce heat — which can be dangerous.

C. Convection is a method of heat loss, not production. It occurs when heat is lost from the body surface to cooler surrounding air (e.g., drafts in the room).

D. Bilirubin conjugation is related to the liver's processing of bilirubin and has nothing to do with thermoregulation.

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During a routine postpartum assessment following a normal vaginal delivery, the nurse notes the fundus is firm, but the level has changed from U-1 to U+1 and deviated to the left. Which action would be appropriate before continuing the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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