Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
72. A client, who is gravida 7, para 6, delivered an infant at 39 weeks' gestation approximately 14 hours ago. Which assessment finding indicates normal postpartum progression?
. Firm fundus at the umbilicus and midline with moderate lochia rubra.
. Firm fundus 1–2 fingerbreadths above the umbilicus and midline with moderate lochia rubra.
. Firm fundus 1–2 fingerbreadths above the umbilicus and deviated to the right side with large lochia rubra.
. Firm fundus 3–4 fingerbreadths below the umbilicus and midline with scant lochia rubra.
Test-Taking Tip
When the options have similarities (in this case, "firm fundus"), ignore that part of the answer and focus on the dissimilarities between the choices.
Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because the fundal height is approximately 2 fingerbreadths below the umbilicus immediately after delivery. The fundal height increases to 1 to 2 fingerbreadths above the umbilicus within 12 hours after delivery. Answer 2 is correct because fundal height increases to 1 to 2 fingerbreadths above the umbilicus within 12 hours after delivery. Answer 3 is incorrect because fundal deviation to the right side indicates a full bladder and risk for uterine atony and hemorrhage. Answer 4 is incorrect because the fundal height is 3 to 4 fingerbreadths below the umbilicus by the fourth to fifth postpartum day.