The nurse palpates a postpartum client's fundus two hours after birth and finds it located to the right of midline and somewhat soft. What does the nurse understand about this information?
The uterine placement is normal
The urinary bladder is distended
The uterus is filled with blood
There is an infection inside the uterus
The Correct Answer is B
A. The uterine placement is not normal if it's to the right of midline. The fundus should be at the midline immediately after birth.
B. The urinary bladder is distended. A full bladder can displace the uterus and cause it to be off- center.
C. The uterus being filled with blood is not the primary reason for the displacement described.
It's more likely due to a distended bladder.
D. Infection inside the uterus is not the primary reason for the displacement described. A distended bladder is a more common cause.
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Related Questions
Correct Answer is C
Explanation
A. Early decelerations are generally considered benign and not an indication for a vaginal exam unless other concerning factors are present.
B. Promptly informing the primary care provider may not be necessary for early decelerations, which are often a normal response to head compression.
C. Continuous monitoring and observation of the client and fetal heart rate are appropriate for early decelerations, especially when the baseline is reassuring and there is moderate variability.
D. Repositioning the client to the left side is a general measure for optimizing fetal oxygenation, but it may not be the priority in the case of early decelerations, which are usually benign and
related to head compression.
Correct Answer is D
Explanation
A. Powers refer to uterine contractions and maternal pushing efforts, which seem appropriate based on the given information.
B. Passage refers to the birth canal, and there is no indication that the birth canal is obstructing the progress.
C. Passenger refers to the fetus, and the cephalic presentation is favorable for a vaginal delivery.
D. The client's psychological state, including fear and anxiety, can impact labor progress. The client's emotional and psychological well-being can influence the progression of labor.
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