Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data from a client who is 12 hr postpartum following a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client's abdomen?
A. Three fingerbreadths above the umbilicus
Choice A reason: Three fingerbreadths above the umbilicus is incorrect, as this position indicates a higher than expected fundal height for a client who is 12 hr postpartum. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one fingerbreadth per day. A high fundal height can indicate uterine atony, retained placental fragments, or bladder distension.
B. One fingerbreadth above the symphysis pubis
Choice B reason: One fingerbreadth above the symphysis pubis is incorrect, as this position indicates a lower than expected fundal height for a client who is 12 hr postpartum. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one fingerbreadth per day. A low fundal height can indicate uterine inversion, which is a rare but life-threatening complication.
C. At the level of the umbilicus
Choice C reason: At the level of the umbilicus is correct, as this position indicates a normal and expected fundal height for a client who is 12 hr postpartum. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one fingerbreadth per day. A midline and firm fundus indicates adequate uterine contraction and involution.
D. To the right of the umbilicus
Choice D reason: To the right of the umbilicus is incorrect, as this position indicates a deviated fundus for a client who is 12 hr postpartum. The fundus should be midline and not displaced to either side. A deviated fundus can indicate bladder distension, which can interfere with uterine contraction and involution. The nurse should assist the client to empty their bladder and reassess the fundal position.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternity Proctored Exam. Take the full exam now
Full Explanation
Choice A reason: Three fingerbreadths above the umbilicus is incorrect, as this position indicates a higher than expected fundal height for a client who is 12 hr postpartum. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one fingerbreadth per day. A high fundal height can indicate uterine atony, retained placental fragments, or bladder distension.
Choice B reason: One fingerbreadth above the symphysis pubis is incorrect, as this position indicates a lower than expected fundal height for a client who is 12 hr postpartum. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one finger-breadth per day. A low fundal height can indicate uterine inversion, which is a rare but life-threatening complication.
Choice C reason: At the level of the umbilicus is correct, as this position indicates a normal and expected fundal height for a client who is 12 hr postpartum. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one finger-breadth per day. A midline and firm fundus indicates adequate uterine contraction and involution.
Choice D reason: To the right of the umbilicus is incorrect, as this position indicates a deviated fundus for a client who is 12 hr postpartum. The fundus should be midline and not displaced to either side. A deviated fundus can indicate bladder distension, which can interfere with uterine contraction and involution. The nurse should assist the client to empty their bladder and reassess the fundal position.
Similar Questions
A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby's mouth, which of the following responses by the nurse is appropriate?
A. "Babies know instinctively exactly how much of the nipple to take into their mouth."
Choice A reason: "Babies know instinctively exactly how much of the nipple to take into their mouth." is incorrect, as this response does not provide adequate guidance or support for the client. Babies may not always latch on correctly or effectively, especially in the first few atempts. The nurse should teach the client how to position and latch the baby properly and observe for signs of effective breastfeeding.
B. "Your baby's mouth is rather small so she will only take part of the nipple."
Choice B reason: "Your baby's mouth is rather small so she will only take part of the nipple." is incorrect, as this response can lead to ineffective breastfeeding and nipple trauma. Taking only part of the nipple can cause poor milk transfer, inadequate milk production, and nipple soreness or cracking. The nurse should teach the client how to ensure that the baby takes enough of the nipple and areola into their mouth.
C. "Try to place the nipple, the entire areola, and some breast tissue beyond the areola into her mouth."
Including too much breast tissue can be uncomfortable. While some areola is important, including too much breast tissue can hinder proper latch and milk flow.
D. "You should place your nipple and some of the areola into her mouth."
Choice D reason: "You should place your nipple and some of the areola into her mouth." This accurately describes the ideal latch for breastfeeding. Including some of the areola helps the baby latch deeply and comfortably, promoting milk transfer and preventing feeding difficulties and nipple soreness.
Full Explanation
Choice A reason: "Babies know instinctively exactly how much of the nipple to take into their mouth." is incorrect, as this response does not provide adequate guidance or support for the client. Babies may not always latch on correctly or effectively, especially in the first few atempts. The nurse should teach the client how to position and latch the baby properly and observe for signs of effective breastfeeding.
Choice B reason: "Your baby's mouth is rather small so she will only take part of the nipple." is incorrect, as this response can lead to ineffective breastfeeding and nipple trauma. Taking only part of the nipple can cause poor milk transfer, inadequate milk production, and nipple soreness or cracking. The nurse should teach the client how to ensure that the baby takes enough of the nipple and areola into their mouth.
Choice C reason: "Try to place the nipple, the entire areola, and some breast tissue beyond the areola into her mouth." -Including too much breast tissue can be uncomfortable. While some areola is important, including too much breast tissue can hinder proper latch and milk flow.
Choice D reason: "You should place your nipple and some of the areola into her mouth." This accurately describes the ideal latch for breastfeeding. Including some of the areola helps the baby latch deeply and comfortably, promoting milk transfer and preventing feeding difficulties and nipple soreness.
A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has a history of genital herpes. Which of the following actions should the nurse take?
A. Request the RN perform a cervical examination.
Choice A reason: Request the RN perform a cervical examination is incorrect, as this action is not indicated for a client who has a history of genital herpes. A cervical examination can introduce infection and trauma to the cervix and increase the risk of viral shedding and transmission to the fetus. The nurse should avoid performing or requesting a cervical examination unless absolutely necessary.
B. Initiate fetal monitoring for baseline and changes.
Choice B reason: Initiate fetal monitoring for baseline and changes is correct, as this action is appropriate for any client who is in labor. Fetal monitoring can provide information about the fetal heart rate, variability, accelerations, decelerations, and contractions. The nurse should monitor the fetal status continuously and report any abnormal findings to the provider.
C. Prepare for a vaginal birth.
Choice C reason: Prepare for a vaginal birth is incorrect, as this action may not be possible for a client who has a history of genital herpes. A vaginal birth can expose the fetus to the herpes virus and cause neonatal infection, which can be life-threatening. The nurse should assess the client for signs of active lesions or prodromal symptoms and prepare for a cesarean birth if indicated.
D. Administer antibiotics.
Choice D reason: Administer antibiotics is incorrect, as this action is not effective for a client who has a history of genital herpes. Genital herpes is caused by a virus, not a bacteria, and antibiotics have no effect on viral infections. The nurse should administer antiviral medications as prescribed to reduce viral shedding and transmission to the fetus.
Full Explanation
Choice A reason: Request the RN perform a cervical examination is incorrect, as this action is not indicated for a client who has a history of genital herpes. A cervical examination can introduce infection and trauma to the cervix and increase the risk of viral shedding and transmission to the fetus. The nurse should avoid performing or requesting a cervical examination unless absolutely necessary.
Choice B reason: Initiate fetal monitoring for baseline and changes is correct, as this action is appropriate for any client who is in labor. Fetal monitoring can provide information about the fetal heart rate, variability, accelerations, decelerations, and contractions. The nurse should monitor the fetal status continuously and report any abnormal findings to the provider.
Choice C reason: Prepare for a vaginal birth is incorrect, as this action may not be possible for a client who has a history of genital herpes. A vaginal birth can expose the fetus to the herpes virus and cause neonatal infection, which can be life-threatening. The nurse should assess the client for signs of active lesions or prodromal symptoms and prepare for a cesarean birth if indicated.
Choice D reason: Administer antibiotics is incorrect, as this action is not effective for a client who has a history of genital herpes. Genital herpes is caused by a virus, not a bacteria, and antibiotics have no effect on viral infections. The nurse should administer antiviral medications as prescribed to reduce viral shedding and transmission to the fetus.
A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes breasts soft, fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?
A. Encourage the client to nurse more frequently so her milk will come in.
Choice A reason: Encourage the client to nurse more frequently so her milk will come in is incorrect, as this action is not related to the data collected by the nurse. The nurse notes that the client's breasts are soft, which indicates that the milk has not come in yet. This is normal and expected for a client who is 14 hr postpartum, as milk production usually begins around 72 to 96 hr after birth. The nurse should encourage the client to nurse frequently and effectively to stimulate milk production and prevent engorgement.
B. Increase IV fluids.
Choice B reason: Increase IV fluids is incorrect, as this action is not indicated by the data collected by the nurse. The nurse notes that the client's vital signs are within normal limits, except for a slight temperature elevation. Increasing IV fluids can cause fluid overload and electrolyte imbalance in the client. The nurse should maintain the IV fluids at the prescribed rate and monitor the client's intake and output.
C. Ask the client to empty her bladder.
Choice C reason: Ask the client to empty her bladder is correct, as this action is indicated by the data collected by the nurse. The nurse notes that the client's fundus is firm but slightly deviated to the right, which suggests bladder distension. A full bladder can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection. The nurse should assist the client to empty their bladder and reassess the fundal position.
D. Report the client's temperature elevation.
Choice D reason: Report the client's temperature elevation is incorrect, as this action is not necessary for a slight temperature elevation in a postpartum client. The nurse notes that the client's temperature is 37.7° C (100° F), which is slightly above normal but within the range of expected findings for a postpartum client. A mild temperature elevation in the first 24 hr after birth can be due to dehydration, exertion, or hormonal changes and does not indicate infection. The nurse should encourage oral fluid intake and monitor the temperature every 4 hr.
Full Explanation
Choice A reason: Encourage the client to nurse more frequently so her milk will come in is incorrect, as this action is not related to the data collected by the nurse. The nurse notes that the client's breasts are soft, which indicates that the milk has not come in yet. This is normal and expected for a client who is 14 hr postpartum, as milk production usually begins around 72 to 96 hr after birth. The nurse should encourage the client to nurse frequently and effectively to stimulate milk production and prevent engorgement.
Choice B reason: Increase IV fluids is incorrect, as this action is not indicated by the data collected by the nurse. The nurse notes that the client's vital signs are within normal limits, except for a slight temperature elevation. Increasing IV fluids can cause fluid overload and electrolyte imbalance in the client. The nurse should maintain the IV fluids at the prescribed rate and monitor the client's intake and output.
Choice C reason: Ask the client to empty her bladder is correct, as this action is indicated by the data collected by the nurse. The nurse notes that the client's fundus is firm but slightly deviated to the right, which suggests bladder distension. A full bladder can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection. The nurse should assist the client to empty their bladder and reassess the fundal position.
Choice D reason: Report the client's temperature elevation is incorrect, as this action is not necessary for a slight temperature elevation in a postpartum client. The nurse notes that the client's temperature is 37.7° C (100° F), which is slightly above normal but within the range of expected findings for a postpartum client. A mild temperature elevation in the first 24 hr after birth can be due to dehydration, exertion, or hormonal changes and does not indicate infection. The nurse should encourage oral fluid intake and monitor the temperature every 4 hr.