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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) 2 to 3 oz (60 to 90 mL):
To determine the appropriate amount of formula for this infant, first calculate the total fluid requirements for the day. The infant weighs 6 lb (2722 g), and newborns typically need 73 mL of fluid per pound of body weight per day.
6 lb × 73 mL = 438 mL of fluid required daily.
Since the infant is fed every 4 hours, this equates to approximately 6 feedings in a 24-hour period.
438 mL ÷ 6 feedings = 73 mL per feeding.
Converting this to ounces (since 1 oz = 30 mL), the infant would need about 2.5 oz per feeding. Therefore, 2 to 3 oz (60 to 90 mL) per feeding is appropriate to meet the infant's daily fluid needs.

B) 1 to 1.5 oz (30 to 45 mL):
This amount is insufficient for the infant’s daily fluid needs. At 1 to 1.5 oz per feeding, the total intake for the day would be only 180 to 270 mL, which is well below the required 438 mL. This could lead to dehydration and inadequate nourishment.

C) 4 to 5 oz (120 to 150 mL):
This amount is excessive for a 3-day-old infant. Newborns typically consume much smaller amounts at each feeding due to their smaller stomach capacity. Overfeeding could lead to discomfort and potential digestive issues.

D) 3 to 4 oz (90 to 120 mL):
While this range is closer to the required amount, it is still slightly too much for a 3-day-old infant. At this age, the recommended amount is closer to 2.5 oz per feeding, so 3 to 4 oz may be excessive and could contribute to overfeeding, which might be uncomfortable for the infant.

A. The woman has laceration B. The woman had her fourth baby C. The woman received epidural anesthesia D. The woman had a vacuum assisted birth

Correct Answer is A

Explanation

A. The woman has a laceration:
The orders for perineal ice packs, sitz baths, and a stool softener suggest that the woman may have sustained perineal trauma, such as a laceration, during childbirth. Ice packs are used initially to reduce swelling and discomfort, while a sitz bath helps with healing and soothing of the perineal area. Stool softeners are prescribed to prevent straining during bowel movements, which could worsen the discomfort of a laceration. These interventions are commonly recommended for women who experience perineal lacerations during vaginal delivery.

B. The woman had her fourth baby:
While the fact that this is the woman’s fourth pregnancy may influence her overall recovery, it is not directly correlated with the orders for ice packs, sitz baths, and stool softeners. Women who have had multiple children may be at a higher risk for perineal trauma due to the stretching of tissues, but this specific care plan is more likely related to a perineal injury, not the number of previous births.

C. The woman received epidural anesthesia:
Epidural anesthesia may be used to manage pain during labor, but it does not directly necessitate the use of ice packs, sitz baths, or stool softeners. While epidurals can sometimes lead to difficulty with bladder or bowel control, they do not typically cause perineal lacerations or require these specific interventions unless there is another issue, such as a laceration, that needs attention.

D. The woman had a vacuum-assisted birth:
Vacuum-assisted births can cause perineal trauma, including lacerations or hematomas, but the order for perineal care (ice packs, sitz baths, stool softeners) is not exclusively linked to vacuum assistance. The woman may have had a laceration during a vacuum-assisted delivery, but it is the laceration itself, rather than the use of the vacuum, that most directly correlates with these interventions. Therefore, the priority care focus is still on addressing the potential for perineal laceration.

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Which finding 12 hours after birth requires further assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 3-day-old infant who weighs 6 lb (2722 g) is fed formula every 4 hours. Newborns require about 73 mL of fluid per pound (454 g) of body weight each day. In light of this information,approximately how much formula should the infant receive at each feeding?

Correct Answer is A

Explanation

A woman gave birth vaginally to a 9-lb, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of sitz bath TID, and a stool softener. What information is most closely correlated with these orders?

Correct Answer is A

Explanation

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