The nurse is assessing a postpartum woman.
The fundus is palpated on the right side of the abdomen above the expected level.
What is the most appropriate first action of the nurse?
Recognize this finding is associated with a hematoma and draw a stat Complete Blood Count (CBC).
Have the woman empty her bladder and then reassess.
Instruct her to change position since she has probably been lying on her right side too long.
Contact the health care provider.
The Correct Answer is B
Choice A rationale
A uterine hematoma typically presents with unrelenting pain and may cause signs of hypovolemic shock, which would be evidenced by tachycardia and hypotension, not necessarily a displaced, high fundus as a primary sign. While a Complete Blood Count (CBC) can detect associated anemia (normal hemoglobin is 12-16 g/dL), the immediate priority is addressing the fundus's position.
Choice B rationale
A full or distended urinary bladder pushes the uterus superiorly and laterally, commonly to the right side due to anatomical arrangement, causing it to be palpable above the expected level. This displacement inhibits proper uterine contraction and increases the risk of postpartum hemorrhage. The most appropriate initial intervention is to have the woman void or catheterize her, then reassess the fundus's position and tone.
Choice C rationale
While prolonged positioning can influence physical findings, the bladder's mechanical displacement of the uterus is a more common and clinically significant cause of a fundus displaced high and to the side in the immediate postpartum period. Simply changing position will not resolve the underlying issue of bladder distension, which compromises uterine hemostasis and must be addressed immediately.
Choice D rationale
While the health care provider must be informed of abnormal findings, contacting them is not the first action when a correctable physiological cause is highly suspected. The nurse should first attempt the least invasive intervention, which is addressing the likely full bladder, a common cause of this finding, and then reassess before escalating care. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Small for gestational age (SGA) is scientifically defined as a newborn whose birth weight is below the 10th percentile for their specific gestational age, indicating restricted fetal growth. These infants have lower glycogen stores, a critical energy source, and decreased gluconeogenesis capacity, leading to rapid depletion of glucose reserves postpartum. This deficiency significantly increases the newborn's risk for hypoglycemia (blood glucose <40 to 45 mg/dL), requiring frequent monitoring and early feeding interventions.
Choice B rationale
A weight below the 5th percentile is a more severe classification, sometimes called severe SGA or fetal growth restriction (FGR), but the general definition of SGA remains the 10th percentile cutoff. While SGA infants may have a higher hematocrit (polycythemia), which is a risk factor for hyperbilirubinemia due to increased red blood cell breakdown, hypoglycemia is the most immediate and common metabolic risk due to low energy stores.
Choice C rationale
A birth weight above the 90th percentile for gestational age defines a large for gestational age (LGA) or macrosomic infant, the complete opposite of SGA. These infants, often born to diabetic mothers, are at a higher risk for birth trauma, shoulder dystocia, and hypoglycemia, but are not defined as SGA. Polycythemia (central hematocrit >65%) is a risk for SGA infants, but SGA is not defined by weight above the 90th percentile.
Choice D rationale
The 50th percentile represents the average or median weight for that gestational age, classifying the infant as appropriate for gestational age (AGA), not SGA. Meconium aspiration syndrome is primarily a risk associated with post-term infants (born ≥42 weeks) or term/SGA infants experiencing fetal distress and asphyxia, which triggers meconium passage in utero, not a direct or defining metabolic risk of SGA.
Correct Answer is {"A":{"answers":"A,E,F"},"B":{"answers":"B,C,D"}}
Explanation
Respiratory distress (pick 3): Retractions, Grunting, Nasal flaring. Expected finding (pick 3): Respiratory Rate of 54 breaths per minute, Acrocyanosis, Abdominal Breathing. .
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