The nurse is assessing four clients on the postpartum unit. Each client's uterine assessment is below. 1. The client is three days postpartum and her fundus is 3 cm below the umbilicus 2. The client is two days postpartum and her fundus is 2 cm above the umbilicus 3. The client is one day postpartum and her fundus is 1 cm below the umbilicus 4. The client delivered 8 hours ago and her fundus is at the umbilicus
Which client is experiencing uterine subinvolution?
4
2
1
3
The Correct Answer is B
A. Client 4, who delivered 8 hours ago, having a fundus at the umbilicus is within the expected range for a client at this stage postpartum.
B. Client 2, two days postpartum with a fundus 2 cm above the umbilicus, is suggestive of uterine subinvolution, as the fundus should be descending, not rising, after delivery.
C. Client 1, three days postpartum with a fundus 3 cm below the umbilicus, is within the expected range for the postpartum period.
D. Client 3, one day postpartum with a fundus 1 cm below the umbilicus, is within the expected range for the postpartum period.
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 B
Explanation
A. Placing the client on her left side is important for optimizing fetal oxygenation but is not the first action when there is a report of a gush of fluid.
B. Notifying the registered nurse (RN) immediately is the first action to ensure prompt assessment and appropriate interventions for possible ruptured membranes.
C. Documenting the time and color of the fluid is important, but immediate notification of the RN takes precedence.
D. Checking fetal heart tones is important but should be done in conjunction with notifying the RN to assess the overall situation and determine the appropriate course of action.
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