the nurse is assessing a postpartum clients fundus where should the nurse expect to find the fundus 24 hours after delivery
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ATI Pediatrics Test Bank

1. The nurse is assessing a postpartum client's fundus. Where should the nurse expect to find the fundus 24 hours after delivery?

Correct answer: A

Rationale: After delivery, the fundus is expected to be at the level of the umbilicus 24 hours postpartum. This position indicates that the uterus is involuting properly. Assessing the fundal height helps monitor the progress of uterine involution and can identify any potential complications like postpartum hemorrhage.

2. The healthcare provider is assessing a newborn who had undergone vaginal delivery. Which of the following findings is least likely to be observed in a normal newborn?

Correct answer: B

Rationale: A heart rate of 80 bpm is least likely to be observed in a normal newborn. The normal heart rate range for a newborn is usually higher than 80 bpm, typically ranging from 120-160 bpm. The Moro reflex (choice A) is a normal newborn reflex, respirations being irregular (choice C) are expected due to the immature respiratory control center, and an uneven head shape (choice D) is common due to molding during vaginal delivery.

3. What is the MOST effective way to prevent cardiopulmonary arrest in a newborn?

Correct answer: A

Rationale: The most effective way to prevent cardiopulmonary arrest in a newborn is to ensure effective oxygenation and ventilation. This is crucial in maintaining adequate oxygen supply and preventing respiratory distress or failure, which are significant factors leading to cardiopulmonary arrest. Providing appropriate ventilation support and oxygenation can help sustain the newborn's vital functions and reduce the risk of cardiopulmonary compromise.

4. Which of the following signs would you expect to see in a child with respiratory failure?

Correct answer: A

Rationale: In a child with respiratory failure, slow, irregular breathing is a common sign. Respiratory failure impairs the ability to exchange oxygen and carbon dioxide efficiently, leading to altered breathing patterns. Flushed skin, a strong cry, or unconsciousness may not be specific signs of respiratory failure and could be indicative of other conditions. Flushed skin may be a sign of fever or increased blood flow, a strong cry may indicate pain or distress, and unconsciousness can have various causes beyond respiratory failure.

5. The student nurse has performed a gestational age assessment of an infant and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment?

Correct answer: B

Rationale: The correct answer is B. At 30 to 32 weeks' gestation, the clitoris is prominent, and the labia minora are enlarging. The labia majora are small and widely separated. As gestational age increases, the labia majora increase in size. At 36 to 40 weeks, they almost cover the clitoris. At 40 weeks and beyond, the labia majora cover the labia minora and clitoris. Choices A, C, and D do not align with the characteristic features seen at 32 weeks of gestation, making them incorrect.

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