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 A
Explanation
A. A pulse rate of 66 beats per minute is within the normal range for a postpartum woman, particularly 12 hours after birth. It's common for the pulse rate to decrease after delivery, as the body stabilizes and returns to its pre-pregnancy state. This is not a cause for concern and can be considered a normal physiological response to the postpartum period.
B. Contact the primary care provider, as it indicates early DIC (disseminated intravascular coagulation). This is unlikely, as DIC typically presents with more severe symptoms, such as bleeding, bruising, and a drop in blood pressure, not a lower pulse rate. A normal or slightly decreased pulse is not indicative of DIC.
C. While it's important to monitor for signs of anemia in the postpartum period (such as fatigue, dizziness, or weakness), a pulse of 66 beats per minute is not a typical sign of anemia. Anemia would more likely be accompanied by other symptoms, such as pallor or weakness.
D. Postpartum eclampsia typically presents with high blood pressure, severe headache, visual disturbances, or seizures, not a low pulse rate. A pulse rate of 66 beats per minute is not a sign of eclampsia.
Correct Answer is D
Explanation
A. Ferrous sulfate is typically prescribed to prevent or treat iron deficiency anemia, which may be needed postpartum if there was significant blood loss during delivery, but it is not related to the care of a perineal laceration.
B. Methylergonovine is a medication used to prevent or treat postpartum hemorrhage by promoting uterine contraction. While it is important for hemorrhage management, it is not used for perineal laceration care.
C. Bromocriptine is used to suppress lactation in clients who are not breastfeeding, but it is not relevant to a fourth-degree laceration.
D. Docusate is a stool softener, which is often prescribed after a fourth-degree perineal laceration. The client needs to avoid straining during bowel movements, as it could put strain on the perineal area and hinder healing. Docusate helps prevent constipation and reduces the risk of further injury to the perineum.
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