Maternity NCLEX Questions | Nurselytic

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Question 1 of 5

The nurse is assessing the postpartum client, who is 5 hours postdelivery. Initially, the nurse is unable to palpate the client’s uterine fundus. Prioritize the nurse’s actions to locate the client’s fundus by placing each step in the correct sequence.

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Place the side of one hand just above the client’s symphysis pubis.
Press deeply into the abdomen.
Place the other hand at the level of the umbilicus.
Massage the abdomen in a circular motion.
Position the client in the supine position.
If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage.

Correct Answer: E,A,C,B,D,F

Rationale: Position the client in supine so the height of the uterus is not influenced by an elevated position. Place the side of one hand just above the client’s symphysis pubis. This supports the lower uterine segment and prevents the inadvertent inversion of the uterus during palpation. Place the other hand at the level of the umbilicus. This is the expected location of the uterine fundus on the day of delivery. Press deeply into the abdomen to allow the massage to reach the fundus. Massage the abdomen in a circular motion. This massage should stimulate the uterus to contract and allow location of the fundus to be determined. If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage. Involution could potentially be occurring more rapidly than expected if the client is breastfeeding and/or had an uncomplicated labor and birth.

Question 2 of 5

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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