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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Powers refer to uterine contractions and maternal pushing efforts, which seem appropriate based on the given information.
B. Passage refers to the birth canal, and there is no indication that the birth canal is obstructing the progress.
C. Passenger refers to the fetus, and the cephalic presentation is favorable for a vaginal delivery.
D. The client's psychological state, including fear and anxiety, can impact labor progress. The client's emotional and psychological well-being can influence the progression of labor.
Correct Answer is A
Explanation
A. Late decelerations are associated with uteroplacental insufficiency, indicating that the baby is not getting enough oxygen during contractions.
B. Maternal hypotension can lead to decreased perfusion but is more likely associated with variable decelerations.
C. Cord compression is often associated with variable decelerations, not late decelerations.
D. Head compression typically does not cause late decelerations; it may be associated with early decelerations.
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