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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
2+ patellar reflex: A hyperactive patellar reflex (also known as a knee-jerk reflex) is a sign of hyperreflexia, which can be a neurological symptom of preeclampsia. Hyperreflexia results from heightened nerve excitability and can manifest as exaggerated reflexes. In preeclampsia, it stems from central nervous system irritability due to cerebral edema or other neurological disturbances.
2+ proteinuria: Proteinuria, defined as the presence of excessive protein in the urine, is a hallmark sign of preeclampsia. It indicates glomerular damage in the kidneys, leading to protein leakage into the urine. The degree of proteinuria is graded on a scale of 1+ to 4+, with 2+ representing a significant level that warrants immediate attention.
Choice B rationale:
24 weeks of gestation: While 24 weeks of gestation is considered early preterm birth, it is not inherently a finding that requires immediate reporting to the RN in the context of postpartum care. The focus on the postpartum unit is primarily on the health of the mother and newborn after delivery, rather than managing ongoing pregnancies.
Choice C rationale:
Preeclampsia: While preeclampsia is a serious condition that necessitates close monitoring and management, the mere diagnosis of preeclampsia without additional concerning findings does not automatically require immediate reporting to the RN. It's essential to assess for specific signs and symptoms that indicate worsening or complications of preeclampsia, such as those mentioned in Choice A.
Choice D rationale:
Heart rate of 100/min: A heart rate of 100 beats per minute is within the normal range for adults, even postpartum. Mild tachycardia (increased heart rate) can be a physiological response to various factors such as pain, anxiety, or exertion, and it does not always signify a serious problem. However, if the heart rate is persistently elevated or accompanied by other concerning symptoms, it would warrant further evaluation.
Correct Answer is A
Explanation
Choice A rationale:
Contraction duration: Contractions that last longer than 75 seconds are considered abnormal and should be reported to the
provider. This is because prolonged contractions can decrease oxygen supply to the fetus, leading to fetal distress.
Risk of uterine rupture: Excessively long contractions can also increase the risk of uterine rupture, a serious complication that
can endanger both the mother and the fetus.
Signs of fetal distress: The nurse should closely monitor the fetal heart rate for any signs of distress, such as late decelerations,
decreased variability, or bradycardia.
Need for intervention: If the contractions remain prolonged or if fetal distress is detected, the provider may need to intervene
to ensure the safety of both the mother and the fetus. This could involve measures such as administering medications to stop
or slow down labor, or performing a cesarean delivery.
Choice B rationale:
Contraction resting period: A contraction resting period of 35 seconds is within the normal range. Ideally, the resting period
between contractions should be at least 60 seconds, but it can vary. However, a resting period shorter than 30 seconds could
be a sign of tachysystole (excessively frequent contractions), which may also require intervention.
Choice C rationale:
Maternal heart rate: A maternal heart rate of 100 beats per minute is considered normal during labor. Heart rate can increase
with exertion, pain, and anxiety, which are common during labor. However, it's important to monitor for significant
tachycardia (heart rate over 120 beats per minute), which could indicate underlying issues such as dehydration or infection.
Choice D rationale:
Contraction frequency: One contraction in a 10-minute period is not indicative of active labor. Labor is typically defined as
having regular contractions that are 5 minutes apart or less, lasting for 45-60 seconds each, and causing progressive cervical
change. In early labor, contractions may be more sporadic and less intense.
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