Health Promotion and Maintenance
71. A nurse assesses a client who delivered an 8-pound, 6-ounce infant 2 hours ago. Which assessment findings are considered "normal" in a client during this time? Select all that apply.
Health Promotion and Maintenance
71. A nurse assesses a client who delivered an 8-pound, 6-ounce infant 2 hours ago. Which assessment findings are considered "normal" in a client during this time? Select all that apply.
. Fundus firm, at the umbilicus.
. Fundus firm, 2 fingerbreadths below the umbilicus.
. Bluish-white fluid expressed from her breasts.
. Lochia serosa, moderate amount.
. Moderate lochia rubra.
Test-Taking Tip
The key to this question is the time frame after delivery. Choose the options that apply to a client 2 hours after delivery.
Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Evaluation; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Health Promotion and Maintenance
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Answer 1 is correct because the fundus is usually at about the level of the umbilicus 2 hours after delivery. Answer 2 is incorrect because the fundus is not found 2 fingerbreadths below the umbilicus until about 48 hours after delivery. Answer 3 is incorrect because bluish-white fluid in milk does not come in until 3 to 4 days after delivery, not 2 hours after delivery. Answer 4 is incorrect because lochia serosa does not occur until about 5 days after delivery, lasting about 5 days. Answer 5 is correct because moderate lochia rubra is a normal finding 2 hours after delivery.