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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Artificial rupture of membranes involves breaking the amniotic sac to induce or augment labor but is not a method for cervical ripening.
B. Laminaria is a common mechanical method used to ripen the cervix before labor induction.
Laminaria tents are placed in the cervix to gradually dilate and soften it.
C. A catheter filled with sterile saline may be used for cervical ripening, but it is not the most common mechanical method.
D. Membrane stripping involves separating the amniotic membrane from the cervix, not a mechanical method for cervical ripening.
Correct Answer is C
Explanation
A. Horizontal does not describe the position of the fetal head in relation to the pelvic station.
B. Engagement typically occurs when the presenting part of the fetus reaches 0 station or is at the level of the ischial spines.
C. At -4 station, the fetal head is considered to be floating, indicating that it has not yet entered the pelvic inlet.
D. Crowning occurs when the fetal head is visible at the vaginal opening during the second stage of labor.
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