The nurse assesses the postpartum client's fundal height and tone in the first 24 hours. Which action will the nurse take to correctly assess the uterine fundus?

Placing index and middle fingers across the uterus

Placing a gloved hand just above the symphysis pubis

Palpating the abdomen while feeling the uterine fundus

Massaging the fundus vigorously to expel any blood clots

Answer and Explanation

The Correct Answer is C

A.   Placing fingers across the uterus is not a standard technique for assessing the uterine fundus postpartum. Palpation is typically performed on the abdomen.
B.   Placing a gloved hand just above the symphysis pubis is more related to assessing descent and engagement of the fetal head during labor, not uterine fundal height.
C.   Palpating the abdomen while feeling the uterine fundus allows the nurse to assess the fundal height, tone, and position.
D.   Massaging the fundus vigorously to expel blood clots is not a recommended practice; gentle massage is performed to assess tone and firmness.

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Correct Answer is ["B"]

Explanation

A. A previous low transverse uterine incision is a factor that may allow for a trial of labor after cesarean (TOLAC) or a vaginal birth after cesarean (VBAC), rather than an automatic cesarean section.
B. Placenta previa, where the placenta partially or completely covers the cervix, often requires a cesarean section to avoid complications such as bleeding during labor.

C. A previous classical uterine incision, especially if it extends into the upper part of the uterus, is a contraindication for a trial of labor or vaginal birth, usually requiring a repeat cesarean
section.

D. Prolapsed umbilical cord, where the cord precedes the presenting part, can lead to cord compression during contractions, necessitating a prompt cesarean section.
E. Breast cancer is not a direct indication for a cesarean section; it does not impact the mode of delivery in the absence of other obstetric indications.

A. Industry vs. inferiority B. Initiative vs. guilt C. Identity vs. role confusion D. Autonomy vs. shame and doubt

Correct Answer is A

Explanation

A. A 9-year-old is in the school-age period, which corresponds to Erikson’s stage of industry vs. inferiority. During this stage, children focus on developing skills, gaining competence, and seeking approval for accomplishments. Supporting independence in asthma care (such as learning to use an inhaler) fosters a sense of industry.
B. Initiative vs. guilt is the stage for preschool-aged children (3–6 years), where the focus is on asserting power and control through play and social interactions.

C. Identity vs. role confusion is more applicable to adolescence and focuses on the formation of a stable self-identity.

D. Autonomy vs. shame and doubt is relevant to the toddler age range, emphasizing the development of independence. While independence is important, the immediate concern in the given scenario aligns more with the initiative and responsibility associated with the school-age child.

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The nurse assesses the postpartum client's fundal height and tone in the first 24 hours. Which action will the nurse take to correctly assess the uterine fundus?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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