A nurse is collecting data from a client who is 12 hours postpartum following a spontaneous vaginal delivery.
The nurse should expect to find the uterine fundus at which of the following positions on the client’s abdomen?
Three fingerbreadths above the umbilicus
At the level of the umbilicus
One fingerbreadth above the symphysis pubis
One fingerbreadth below the umbilicus
The Correct Answer is B
Choice A rationale:
Three fingerbreadths above the umbilicus is too high for the uterine fundus to be at 12 hours postpartum. Immediately after delivery, the fundus is typically at the level of the umbilicus. It then descends approximately one fingerbreadth per day.
If the fundus is found to be three fingerbreadths above the umbilicus at 12 hours postpartum, it could be a sign of uterine atony, which is a serious condition that can lead to postpartum hemorrhage.
Choice C rationale:
One fingerbreadth above the symphysis pubis is too low for the uterine fundus to be at 12 hours postpartum. This would be more consistent with a woman who is several days postpartum.
Choice D rationale:
One fingerbreadth below the umbilicus is also too low for the uterine fundus to be at 12 hours postpartum. This would be more consistent with a woman who is 1-2 days postpartum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Retraction of the fetal head against the maternal perineum is a classic sign that the shoulders are about to be delivered. This is
known as the "turtle sign" because the fetal head appears to retract back into the body like a turtle's head.
It is important for the nurse to be prepared to assist with the delivery of the shoulders to ensure a safe and smooth delivery.
This includes:
Positioning the mother appropriately, such as in the McRoberts maneuver or a hands-and-knees position.
Applying gentle downward traction on the fetal head to help deliver the anterior shoulder.
Rotating the fetal shoulders as needed to facilitate delivery.
Monitoring the fetal heart rate closely for any signs of distress.
Choice B rationale:
While encouraging the mother to rest between contractions is important for conserving energy, it is not the priority action
when the fetal head is retracting. The nurse's focus should be on preparing for the delivery of the shoulders.
Choice C rationale:
Checking the mother's blood pressure is a routine part of labor and delivery care, but it is not specifically indicated when the
fetal head is retracting. There is no evidence to suggest that retraction of the fetal head is associated with changes in maternal
blood pressure.
Choice D rationale:
Administering oxygen to the mother may be helpful in some cases, such as if the fetal heart rate is showing signs of distress.
However, it is not the priority action when the fetal head is retracting. The focus should be on preparing for the delivery of the
shoulders.
Correct Answer is B
Explanation
Choice A rationale:
Placing a soft pillow under the client's buttocks is not recommended for episiotomy pain relief. It can actually increase pain by placing pressure on the perineum and impeding blood flow to the area. This can hinder healing and prolong discomfort.
Additionally, it can separate the buttocks, potentially decreasing venous return and further exacerbating pain.
Choice C rationale:
Positioning a heating lamp toward the episiotomy is not appropriate within the first 24 hours following delivery. Heat application during this early stage can increase inflammation and swelling, potentially worsening pain and delaying healing.
Heat therapy is typically recommended after 24 hours to promote circulation and tissue repair, but it's crucial to apply it at the appropriate time.
Choice D rationale:
Preparing a warm sitz bath is a common comfort measure for postpartum perineal care, but it's generally recommended after
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