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":"B","dropdown-group-2":"B"}
Explanation
The nurse should recognize that the client is at risk of postpartum hemorrhage due to polyhydramnios.
Risk:
Postpartum Hemorrhage (PPH): The client has polyhydramnios and multiple gestation, which cause uterine overdistension. Overdistension increases the risk of uterine atony postpartum, a leading cause of PPH. Other contributing factors are the large uterine fibroids and a history of preterm labor.
Probable Cause:
Polyhydramnios: AFI of 30 cm indicates polyhydramnios, which is excess amniotic fluid.
Multiple gestation (twins) is a common cause of polyhydramnios. Polyhydramnios increases the risk of preterm labor, cord prolapse, and PPH.
Correct Answer is B
Explanation
A. Respiratory rate of 16 breaths/min: Normal range, no intervention needed.
B. Pulse of 120 beats per minute: Correct. Tachycardia in the postpartum period can indicate hemorrhage or hypovolemia, requiring immediate assessment and intervention.
C. Temperature of 98.8°F (37.7°C): Normal postpartum temperature.
D. Blood pressure of 120/88 mmHg: Normal postpartum blood pressure.
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