Which of the following findings should alert a nurse assessing a client who is 8 hr postpartum and multiparous?

Fundus three fingerbreadths above the umbilicus.

Moderate lochia rubra.

Blood pressure 130/84 mm Hg.

Moderate swelling of the labia.

Answer and Explanation

The Correct Answer is A

Choice A rationale
A fundus that is three fingerbreadths above the umbilicus 8 hours postpartum is a sign of urinary retention, which can displace the uterus and inhibit uterine contraction, leading to postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra, or bloody discharge, is normal within the first few days after childbirth.
Choice C rationale
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum woman.
Choice D rationale
Moderate swelling of the labia can be a normal finding after a vaginal birth.

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Correct Answer is C

Explanation

Choice A rationale
While it’s important to report concerns to the primary care provider, this does not directly address the mother’s concern about her newborn’s crossed eyes.
Choice B rationale
Strabismus is a condition where the eyes do not properly align with each other, but it is not the same as the normal crossing of a newborn’s eyes.
Choice C rationale
This is the correct answer. Newborns often lack the muscle control to regulate eye movement, which can cause their eyes to cross.
Choice D rationale
Taking the baby to the nursery for further examination may be necessary if there are other concerns, but it does not directly address the mother’s concern about her newborn’s crossed eyes.

A. Fundus soft, 1 cm to the right of the umbilicus. B. Fundus soft, 2 cm above the umbilicus. C. Fundus firm, at the level of the umbilicus. D. Fundus present, to the left of the umbilicus.

Correct Answer is C

Explanation

Choice A rationale
The fundus should not be soft or to the right of the umbilicus 12 hours postpartum. A soft or displaced fundus could indicate uterine atony or a full bladder, both of which require intervention.
Choice B rationale
The fundus should not be soft or above the umbilicus 12 hours postpartum. This could indicate uterine atony, which could lead to postpartum hemorrhage.
Choice C rationale
The fundus should be firm and at the level of the umbilicus 12 hours postpartum. This indicates that the uterus is contracting properly to prevent excessive bleeding.
Choice D rationale
The fundus should not be to the left of the umbilicus 12 hours postpartum. This could indicate a full bladder, which can displace the uterus and interfere with uterine contractions

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Which of the following findings should alert a nurse assessing a client who is 8 hr postpartum and multiparous?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a new mother who is worried about her newborn’s crossed eyes. Which of the following responses by the nurse would be therapeutic?

Correct Answer is C

Explanation

A nurse is caring for a client who is 12 hours postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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