45. A client, who is gravida 4, para 3, delivered a 7-pound, 3-ounce neonate at 38 weeks' gestation about 24 hours ago. Upon assessment, where should a nurse expect to palpate the client's fundus?
45. A client, who is gravida 4, para 3, delivered a 7-pound, 3-ounce neonate at 38 weeks' gestation about 24 hours ago. Upon assessment, where should a nurse expect to palpate the client's fundus?
. At the level of the symphysis pubis.
. Midway between the umbilicus and the symphysis.
. At the level of the xyphoid process.
. At the level of the umbilicus.
Test-Taking Tip
Focus on the anatomical landmarks of the symphysis and the xyphoid process. Eliminate the option that is not consistent with a 24-hours-postdelivery fundus.
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
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Answer 1 is incorrect because the fundus does not descend to the level of the symphysis pubis until about the 10th postpartum day. Answer 2 is incorrect because the fundus immediately after delivery is contracted to the level halfway between the umbilicus and the symphysis. But by 24 hours after delivery, the fundus rises to the level of the umbilicus, and then decreases about a fingerbreadth per day after delivery. Answer 3 is incorrect because the xyphoid process is approximately where the fundus is found before delivery. Answer 4 is correct because the fundus would be about the level of the umbilicus 24 hours after delivery. It rises up about 1 cm above the umbilicus about 12 hours after delivery. Then at 24 hours after delivery it is back to the level of the umbilicus, and then decreases about a fingerbreadth per day after delivery.