You are assessing a patient who delivered vaginally 48 hours ago. At this time, where would you expect to feel her fundus?
level of umbilicus
1 fingerbreadth/cm below umbilicus
2 fingerbreadth/cm below umbilicus
3 fingerbreadth/cm below umbilicus
The Correct Answer is C
A. This is expected immediately postpartum.
B. This is expected at 24 hours postpartum.
C. Immediately after birth, the fundus is at the level of the umbilicus. The uterus involutes (shrinks) approximately 1 cm (or 1 fingerbreadth) per day postpartum. 48 hours postpartum, the fundus should be 2 cm (or 2 fingerbreadths) below the umbilicus.
D. 3 cm below the umbilicus would be expected at 72 hours postpartum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A"}
Explanation
Massage the fundus: The client has heavy lochia rubra with clots, which indicates possible postpartum hemorrhage (PPH). A firm fundus does not rule out excessive bleeding, so fundal massage and further assessment are critical.
PPH is a life-threatening condition and must be addressed immediately.
Incorrect Answers & Rationale:
Encourage the client to ambulate: While ambulation is important postpartum, it is not the priority in the presence of heavy bleeding.
The client should remain in bed until bleeding is controlled.
Offer the client fluids: Fluids are beneficial but do not address the immediate concern of heavy bleeding. PPH requires active intervention, not just hydration.
Administer pain medication for postpartum discomfort: Pain relief is important, but postpartum hemorrhage is the priority. Uncontrolled bleeding is life-threatening and must be managed first.
Correct Answer is D
Explanation
A. Acetaminophen is an appropriate analgesic for postpartum pain relief.
B. Encouraging oral fluids is essential for hydration, bowel function, and healing.
C. A sitz bath is beneficial for perineal healing, reducing pain and inflammation.
D. Correct. Enemas are contraindicated in clients with fourth-degree perineal lacerations because they may cause trauma, pain, and further damage to the perineal area. Stool softeners are preferred to prevent straining.
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