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. The image does not show variable decelerations
B. The tracing shows a decrease in the fetal heart rate that occurs during the peak of the uterine contraction and returns to the baseline after the end of the contraction. This pattern indicates a late deceleration
C. The image does not show prolonged decelerations
D. The image does not show late decelerations
Correct Answer is D
Explanation
A. An inverted nipple is not indicative of mastitis.
B. Presence of breast milk is expected postpartum and does not specifically indicate mastitis.
C. A bruised area is not a common sign of mastitis.
D. Mastitis often presents with localized pain, redness, swelling, and a hardening of the affected area of the breast. Asking about the presence of a hardening will help assess for mastitis.
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