Nokea
Where can the nurse expect to palpate the fundus at this time?
- A. Just above the symphysis pubis
- B. Just below the xiphoid process
- C. Near the level of the umbilicus
- D. Just below the symphysis pubis
Correct Answer: C
Rationale: At 20 weeks' gestation, the fundus is typically palpated near the level of the umbilicus, reflecting uterine growth.
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The client, who delivered a 4200-g baby 4 hours ago, continues to have bright red, heavy vaginal bleeding. The nurse assesses the client’s fundus and finds it to be firm and midway between the symphysis pubis and umbilicus. What should the nurse do next?
- A. Continue to monitor the client’s bleeding and weigh the peripads.
- B. Call the client’s HCP and request an additional visual examination.
- C. Prepare to give oxytocin to stimulate uterine muscle contraction.
- D. Document the findings as normal with no interventions needed at that time.
Correct Answer: B
Rationale: Although the nurse would definitely need to continue to monitor the amount and quality of bleeding, additional intervention is also needed. The nurse should consider the possibility of a vaginal wall or cervical laceration, which could produce heavy, bright red bleeding. The HCP should be notified and asked to perform a visual exam of the vagina to assess for possible lacerations in need of repair. Preparing to administer oxytocin (Pitocin) would be appropriate if the source of bleeding was suspected to be uterine atony, but the uterus is firm and in the expected location. Documenting the findings without further intervention would lead to a failure to identify the source of increased bleeding resulting in possible client injury. Further assessments and interventions are needed.
The postpartum client, who is 24 hours post—cesarean section, tells the nurse that she has much less lochial discharge after this birth than with her vaginal birth 2 years ago. The client asks if this is normal after a cesarean birth. Which statement should be the basis for the nurse’s response?
- A. A decrease in her lochia is not expected; further assessment is needed.
- B. Women usually have increased lochial discharge after cesarean births.
- C. Women normally have less lochial discharge after a cesarean birth.
- D. The lochia amount depends on whether surgery was emergent or planned.
Correct Answer: C
Rationale: A decrease in lochia is expected after a cesarean birth; no further assessment is needed regarding the lochial amount unless it is totally absent. A decrease in lochia is expected after a cesarean birth, not an increase. The client’s lochial discharge is usually decreased after cesarean birth because the uterus is cleaned during surgery. The amount of lochia is not dependent on whether the surgery was emergent or planned because the uterus is cleaned during surgery in both situations.
Which position should the nurse recommend for early labor?
- A. Lying flat on the back
- B. Walking or standing
- C. Sitting upright
- D. Kneeling on all fours
Correct Answer: B
Rationale: Walking or standing in early labor promotes progress and comfort, unlike lying flat, which may slow labor.
The nurse explains to the group that frequent urination during early pregnancy usually subsides at which time?
- A. When the placenta is fully developed
- B. When fetal kidneys begin to function
- C. When the uterus rises into the abdominal cavity
- D. When the hormonal balance is reestablished
Correct Answer: C
Rationale: Frequent urination subsides in the second trimester as the uterus rises into the abdominal cavity, reducing bladder pressure.
The pregnant client has been pushing for 2½ hours. After some difficulty, the large fetal head emerges. The HCP attempts to deliver the shoulders without success. Place the nurse’s actions in caring for this client in the correct sequence.
- A. Apply suprapubic pressure per direction of the HCP.
- B. Place the client in exaggerated lithotomy position.
- C. Catheterize the client’s bladder.
- D. Call for the neonatal resuscitation team to be present.
- E. Prepare for an emergency cesarean birth.
Correct Answer: D,B,A,C,E
Rationale: Call for the neonatal resuscitation team to be present because of fetal distress. Place the client in exaggerated lithotomy position so the McRoberts’ maneuver can be performed (flexing her thighs sharply on her abdomen may widen the pelvic outlet and let the anterior shoulder be delivered). Apply suprapubic pressure per direction of the HCP. This is completed in an effort to dislodge the shoulder from under the pubic bone. Catheterize the client’s bladder. This will empty the bladder to make more room for the fetal head. Prepare for an emergency cesarean birth. This will be performed if all efforts for a vaginal birth fail.