The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus?
2 cm below the umbilicus
cannot be palpated
6 cm below the umbilicus
halfway below the umbilicus
The Correct Answer is A
A. By 12 days postpartum, the fundus should be about 2 cm below the umbilicus, as the uterus is returning to its pre-pregnancy size. This is a normal finding at this stage of postpartum recovery.
B. At 12 days postpartum, the fundus should still be palpable, though it will be much lower than in the immediate postpartum period.
C. This is too low for 12 days postpartum. The fundus should not descend this far yet.
D. Halfway below the umbilicus would be expected around 7-10 days postpartum, but by 12 days, the fundus should be about 2 cm below the umbilicus, indicating more involution.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Short duration of labor is not typically associated with subinvolution. In fact, prolonged labor (not short) can be a risk factor due to increased uterine fatigue.
B. Use of anesthetics is correct. The use of certain anesthetics during labor, especially those that affect uterine tone (like general anesthesia or high doses of regional anesthesia), can contribute to uterine atony, which may lead to subinvolution—a condition where the uterus does not return to its normal size after childbirth.
C. Early ambulation actually promotes uterine involution and prevents complications like thrombophlebitis, making it a protective factor, not a contributing one.
D. Breastfeeding stimulates the release of oxytocin, which causes uterine contractions and promotes involution, making it a helpful factor in preventing subinvolution.
Correct Answer is A
Explanation
A. Temperature of 101° F (38.3° C) is concerning as it may indicate an infection, especially if it persists beyond the first 24 hours postpartum. A mild increase in temperature can be common during the first 24 hours after birth due to the physical stress of labor and delivery, but a temperature of 101° F is above the normal postpartum range and warrants further investigation for possible infection, such as endometritis or a urinary tract infection.
B. Respiratory rate of 16 breaths per minute is within the normal range for a postpartum woman, as normal respiratory rate is typically between 12 and 20 breaths per minute in adults. No immediate concerns are suggested by this finding.
C. Lochia rubra with a fleshy odor is a normal finding during the first few days postpartum. Lochia rubra, the initial discharge after childbirth, typically has a fleshy or musty odor and contains blood, mucus, and tissue from the uterine lining. A foul or offensive odor, however, would be indicative of infection, but a "fleshy" odor is normal.
D. Pain rating of 2 on a scale from 0 to 10 is within an acceptable range for postpartum pain. Mild discomfort is expected, especially around the perineum or from uterine contractions, and can usually be managed with over-the-counter pain relievers. A pain level of 2 suggests that the patient is coping well.
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