What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery?
Relaxed with its upper border two or three fingerbreadths below the umbilicus
Well-contracted with its upper border at or just below the umbilicus
Relaxed with its upper border level with the umbilicus
Well-contracted with its upper border three or four fingerbreadths above the umbilicus
The Correct Answer is B
A. Relaxed with its upper border two or three fingerbreadths below the umbilicus: A relaxed (boggy) fundus increases the risk of postpartum hemorrhage. Immediately after delivery, the uterus should be firm, not boggy, to ensure proper contraction and minimize bleeding.
B. Well-contracted with its upper border at or just below the umbilicus: Immediately postpartum, the uterus is expected to be firm and at or just below the level of the umbilicus. This indicates effective contraction, which is essential for controlling postpartum bleeding and initiating uterine involution.
C. Relaxed with its upper border level with the umbilicus: A soft fundus at the level of the umbilicus suggests uterine atony, which is abnormal and requires prompt intervention to prevent hemorrhage.
D. Well-contracted with its upper border three or four fingerbreadths above the umbilicus: The fundus is not expected to be this high immediately after delivery. A significantly elevated fundus may indicate a full bladder or retained products of conception and requires assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Report the discrepancy to the pediatrician immediately: While significant or excessive weight loss should be reported, mild physiologic weight loss in the first few days of life is expected. Immediate reporting is not necessary if the loss is within the normal range of 5–10% of birth weight.
B. Decrease the interval between the infant's feedings: Newborns typically lose some weight in the first 3–5 days due to fluid shifts and limited intake. Increasing the frequency of feedings helps ensure adequate caloric intake and promotes gradual weight gain, supporting healthy growth and hydration.
C. Do nothing because this is a normal occurrence: Although some weight loss is normal, the nurse should take action to support feeding and monitor ongoing weight trends rather than ignoring the loss entirely.
D. Try feeding the infant a different type of formula: Changing formula is not indicated unless the infant has feeding intolerance or a medical reason. The initial intervention should focus on optimizing feeding frequency and technique rather than switching formula.
Correct Answer is C
Explanation
A. Ask the mother to identify herself verbally: While verbal identification is helpful, it is not sufficient alone to ensure accurate matching of mother and infant. Reliance solely on verbal confirmation may lead to errors.
B. Confirm room number of mother: Room number may change or be shared in some units, making it an unreliable sole method for verifying identity. It does not guarantee the infant matches the correct mother.
C. Check the band number of the infant with that of the mother: Matching identification bands on both the infant and mother is the most reliable method to ensure correct maternal-infant pairing. This procedure reduces the risk of misidentification and ensures infant safety.
D. Ask, "Is this your band number?": Asking the mother to confirm a number without verification by staff is not a secure method. Human error or miscommunication could result in mismatching, making this approach insufficient for security purposes.
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