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:
Normal progression of labor: After the fetal head is delivered, the shoulders typically follow immediately. The nurse should be prepared to assist with the delivery of the shoulders to ensure a safe and smooth birth process.
Significance of retraction: Retraction of the fetal head against the maternal perineum, also known as the "turtle sign," is a classic indicator of shoulder dystocia. While this sign does not guarantee shoulder dystocia, it warrants immediate preparation for potential management.
Anticipating shoulder dystocia: By anticipating the possibility of shoulder dystocia, the nurse can take proactive measures to minimize risks and facilitate delivery. These measures may include:
Positioning the mother appropriately (e.g., McRoberts maneuver)
- Applying suprapubic pressure
- Performing internal maneuvers (e.g., Rubin's maneuver)
- Breaking the clavicle (in extreme cases)
Choice B rationale:
Ineffective in shoulder dystocia: Encouraging the mother to push during the next contraction is not an effective intervention
for shoulder dystocia. In fact, excessive pushing can worsen the impaction of the shoulders and potentially lead to
complications such as fetal hypoxia, brachial plexus injury, or maternal perineal trauma.
Choice C rationale:
Necessary in confirmed dystocia: Calling for additional medical support is crucial if shoulder dystocia is confirmed. However,
immediate preparation for shoulder delivery should commence without delay, as prompt action is essential to prevent adverse
outcomes.
Choice D rationale:
Secondary concern: While pain relief medication may be administered for maternal comfort, it is not a priority intervention in
this situation. The primary focus should be on managing the potential shoulder dystocia and ensuring the safe delivery of the
baby.
Correct Answer is C
Explanation
The correct answer is choice c. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines.
Choice A rationale:
This choice incorrectly states that the cervix is effaced 3 cm and dilated 30%. Effacement is measured in percentages, not centimeters, and dilation is measured in centimeters, not percentages.
Choice B rationale:
This choice correctly states the cervix is dilated 3 cm and effaced 30%, but it incorrectly states that the presenting part is 1 cm below the ischial spines. A station of -1 means the presenting part is 1 cm above the ischial spines.
Choice C rationale:
This choice correctly states that the cervix is dilated 3 cm, effaced 30%, and the presenting part is 1 cm above the ischial spines. This matches the documentation provided.
Choice D rationale:
This choice incorrectly states that the cervix is effaced 3 cm and dilated 30%. Effacement is measured in percentages, not centimeters, and dilation is measured in centimeters, not percentages. Additionally, it incorrectly states that the presenting part is 1 cm below the ischial spines. A station of -1 means the presenting part is 1 cm above the ischial spines.
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