The nurse is palpating a patient’s uterus 12 hours after a vaginal delivery. For which reason does the nurse place one hand just above the symphysis pubis?

To prevent uterine prolapse

To prevent uterine hemorrhage

To prevent uterine inversion

To stabilize the lower uterine segment

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. To stabilize the lower uterine segment. Palpating the uterus after delivery helps to determine its size, firmness and rate of descent, which are indicators of its involution. The nurse places one hand just above the symphysis pubis to support the lower uterine segment and prevent it from being pushed down by the pressure of the other hand on the fundus. This prevents complications such as uterine inversion or prolapse.

Choice A is wrong because uterine prolapse is not prevented by placing one hand above the symphysis pubis, but by supporting the lower uterine segment with that hand.

Choice B is wrong because uterine hemorrhage is not prevented by placing one hand above the symphysis pubis, but by massaging the fundus to make it firm and contract the blood vessels.

Choice C is wrong because uterine inversion is not prevented by placing one hand above the symphysis pubis, but by stabilizing the lower uterine segment with that hand and avoiding excessive traction on the umbilical cord.

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Correct Answer is C

Explanation

The correct answer is choice C. “I am starting to feel like I can handle being a mother.” This statement indicates that the client is in the informal stage of maternal role attainment, which is characterized by a sense of confidence and competence in the maternal role.

The client develops her own style of mothering and integrates feedback from others.

Choice A is wrong because it reflects the initial stage of maternal role attainment, which is marked by a strong emotional attachment to the newborn.

Choice B is wrong because it suggests that the client is in the formal stage of maternal role attainment, which involves learning the skills and behaviors of mothering from external sources such as healthcare providers and family members.

Choice D is wrong because it implies that the client is in the anticipatory stage of maternal role attainment, which occurs during

A. Place the patient on the left side. B. Assess the passage of lochia. C. Ask the patient to void. D. Administer a dose of oxytocin

Correct Answer is C

Explanation

The correct answer is choice C. Ask the patient to void.This is because a full bladder can displace the uterus and interfere with its contraction, which can lead to postpartum hemorrhageThe nurse should assess the patient’s uterus after ensuring that the bladder is empty.

Choice A is wrong because placing the patient on the left side does not affect the uterus assessment.It may help with blood circulation and oxygenation, but it is not necessary before checking the uterus.

Choice B is wrong because assessing the passage of lochia is part of the uterus assessment, not a prerequisite.Lochia is the vaginal discharge after giving birth, containing blood, mucus, and uterine tissueIt has three stages: lochia rubra (red), lochia serosa (pinkish brown), and lochia alba (yellowish white)

Choice D is wrong because administering a dose of oxytocin is not required before assessing the uterus.

Oxytocin is a hormone that stimulates uterine contractions and reduces bleeding.It may be given during or after labor to prevent or treat postpartum hemorrhage, but it is not a routine procedure.

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The nurse is palpating a patient’s uterus 12 hours after a vaginal delivery. For which reason does the nurse place one hand just above the symphysis pubis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the informal stage of maternal role attainment. Which of the following statements by the client indicates an understanding of this stage?

Correct Answer is C

Explanation

The nurse is providing postpartum care to a patient 24 hours after a vaginal delivery. Which action does the nurse perform prior to assessing the patient’s uterus?

Correct Answer is C

Explanation

A nurse is assessing a postpartum client who received Rho (D) immune globulin (RhoGAM) before discharge. Which statement by the client indicates a need for further teaching?

A nurse is caring for a postpartum client who has decided not to breastfeed her infant and has chosen formula feeding instead. The nurse should instruct the client that:

A nurse is reviewing the laboratory results of a postpartum client who had a hemorrhage due to uterine atony. Which finding would be expected in this client?

A nurse is assessing a postpartum client who delivered her second baby 3 days ago. The client says, “I feel sad that my older child will not get as much attention from me as before.” The nurse recognizes that the client is in which phase of maternal role attainment?

A client is concerned about the risk factors for pre-term labor. Which of the following factors should the nurse include in the discussion?

A nurse is providing discharge teaching to a postpartum client who had a vaginal delivery with an episiotomy. The client asks, “How can I take care of myself at home?” Which of the following responses should the nurse give?

A nurse is evaluating the effectiveness of antenatal education on a group of expectant mothers. Which of the following outcomes would indicate a positive effect of the education?

A nurse is reviewing the medical records of four clients who are pregnant and planning to have a vaginal birth after cesarean (VBAC). Which of the following clients has the highest risk of uterine rupture during labor?