Which finding 12 hours after birth requires further assessment?
The fundus is palpable two fingerbreadths above the umbilicus.
The fundus is palpable at the level of the umbilicus.
The fundus is palpable one fingerbreadth below the umbilicus.
The fundus is palpable two fingerbreadths below the umbilicus.
The Correct Answer is D
A. The fundus is palpable two fingerbreadths above the umbilicus:
While it is higher than expected, this finding may occur if the uterus is still contracting and involuting, as it can sometimes be positioned slightly higher. However, this is not necessarily a cause for concern, and further assessment would depend on other factors like bleeding or discomfort. If the fundus is firm and contractions are present, this finding may still be within a normal range.
B. The fundus is palpable at the level of the umbilicus:
At 12 hours postpartum, the fundus should generally be at the level of the umbilicus. This is an expected finding in the immediate postpartum period as the uterus is beginning to involute. No further action is required unless other complications, like excessive bleeding or signs of infection, are present.
C. The fundus is palpable one fingerbreadth below the umbilicus:
This is another typical finding 12 hours after birth. By this time, the uterus should be involuting and should be slightly below the umbilicus. A slight descent of the fundus is normal as the uterus shrinks and contracts. As long as the fundus is firm and there are no other concerning signs, this is a normal finding.
D. The fundus is palpable two fingerbreadths below the umbilicus:
A fundus palpated two fingerbreadths below the umbilicus 12 hours postpartum suggests that involution may not be progressing as expected. It could indicate uterine atony, where the uterus is not contracting effectively, increasing the risk for postpartum hemorrhage. This requires further assessment to rule out complications such as retained placental fragments or excessive bleeding. Immediate action, including uterine massage or other interventions, may be needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) It could make respiratory distress syndrome worse:
The most critical reason to protect a preterm infant from cold stress is that hypothermia can exacerbate respiratory distress syndrome (RDS). Cold stress leads to an increased oxygen demand, which can worsen the infant’s already compromised respiratory function. In preterm infants, the immature lungs and underdeveloped surfactant production contribute to RDS, and hypothermia worsens the situation by increasing metabolic demands and impairing pulmonary function. Maintaining a stable body temperature is crucial for minimizing respiratory complications.
B) Shivering to produce heat may use up too many calories:
While it is true that preterm infants may not have the metabolic reserves to generate heat via shivering (as they lack significant brown fat), the primary concern is not shivering. Preterm infants generally do not shiver, and cold stress does not trigger this response. Instead, their body tries to conserve heat through vasoconstriction and increased metabolism, which can lead to hypoxia and worsening respiratory distress.
C) A low temperature may make the infant less able to digest nutrients:
Cold stress can affect a preterm infant’s gastrointestinal function by reducing blood flow to the digestive organs, which can impair nutrient absorption and digestion. However, the most immediate and serious consequence of cold stress is the increased metabolic demand and worsening of respiratory distress, rather than a direct impact on digestion. Protecting the infant from hypothermia helps prevent these secondary complications.
D) Cold decreases circulation to the extremities:
While cold stress can indeed lead to vasoconstriction and decreased circulation to the extremities, this is not the most significant concern. The primary issue with cold stress in preterm infants is the overall increase in metabolic demands, oxygen consumption, and exacerbation of respiratory problems, which can lead to more severe respiratory distress syndrome. The loss of peripheral circulation is a secondary concern.
Correct Answer is A
Explanation
A) Put baby to breast for non-nutritive sucking to calm baby:
Non-nutritive sucking (sucking without feeding) is a natural way for babies to self-soothe. It can help calm a fussy infant and also promote bonding between mother and baby. This action also stimulates milk production in the mother. It's a safe and effective way to comfort the baby without introducing unnecessary interventions. Non-nutritive sucking can help regulate the baby's sucking reflexes and provide comfort until the next feeding.
B) Give the baby pacifier:
While pacifiers can help some babies self-soothe, they can interfere with breastfeeding, especially in the early days. Introducing a pacifier too soon may confuse the baby’s natural sucking pattern and affect the latch, which can impact breastfeeding success. It’s typically recommended to wait until breastfeeding is well-established, around 3-4 weeks, before introducing a pacifier.
C) Put the baby in the nursery so mom can get some rest:
While maternal rest is important, removing the baby from the mother's care in the early postpartum period may interfere with the breastfeeding process. Breastfeeding on demand is crucial for establishing a good milk supply, and keeping the baby close for frequent feedings (and comfort) will help with this. Encouraging rest is important, but it shouldn't come at the expense of bonding and feeding.
D) Supplement with formula:
There is no indication that the baby is not getting enough nutrition at this point. Fussy behavior between feedings is common in newborns and can be due to various factors such as the baby's need for comfort, a growth spurt, or a short interval between feedings. Supplementing with formula is not necessary unless there is a clear indication of inadequate milk supply or other medical concerns, which isn’t evident in this situation.
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