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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Nursing Elites

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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. A 4-year-old boy with a tracheostomy tube is experiencing respiratory distress. He has intercostal retractions, a heart rate of 80 beats/min, and an oxygen saturation of 85%. During his attempts to breathe, a gurgling sound is heard in the tracheostomy tube. You should:

Correct answer: D

Rationale: In this scenario, the 4-year-old boy with a tracheostomy tube is showing signs of respiratory distress, including intercostal retractions, a low heart rate, and decreased oxygen saturation. The gurgling sound indicates a possible airway obstruction. Correctly, the immediate action should be to carefully suction the tracheostomy tube. Suctioning can help clear any secretions or obstructions, thus improving the child's ability to breathe effectively. Ventilating through the tube, placing an oxygen mask over it, or removing and cleaning the tube would not address the potential obstruction and could worsen the respiratory distress.

3. A toddler is admitted to the hospital because of sudden hoarseness, holding or pointing to their neck, and continuous cough. The nurse will be particularly concerned about:

Correct answer: B

Rationale: In a toddler presenting with sudden hoarseness, holding or pointing to their neck, and continuous cough, the nurse should be particularly concerned about respiratory tract obstruction caused by a foreign body. These symptoms are indicative of a possible foreign body in the airway, which can lead to serious complications and requires immediate attention to ensure the toddler's airway remains patent and unobstructed.

4. A 3-month-old is hospitalized with a fractured femur. The pain assessment tool most appropriate for this child is the:

Correct answer: A

Rationale: The FLACC scale is a validated pain assessment tool suitable for infants and young children, including 3-month-olds. It assesses pain based on five categories: Face, Legs, Activity, Cry, and Consolability. Since infants cannot communicate their pain verbally, the FLACC scale is effective in evaluating pain by observing these behavioral indicators. The other options, such as the Poker chip tool, Number scale, and Visual analog scale, are not specifically designed for infants and may not provide accurate pain assessment in this age group.

5. When evaluating a client's fluid intake and output record, how should fluid intake and urine output relate?

Correct answer: B

Rationale: In assessing a client's fluid intake and output record, it is essential for fluid intake to be approximately equal to the urine output. This balance indicates proper hydration and renal function. Deviations from this balance could signify potential issues that need further investigation and management.

Similar Questions

Which of the following findings is abnormal?
Which statement best describes direct contact as a mode of pathogen transmission?
When a father asks why his child with tetralogy of Fallot seems to favor a squatting position, the nurse would explain that squatting:
A postpartum client who delivered a healthy newborn is being assessed by a nurse. Which finding would indicate a complication during the early postpartum period?
Which of the following statements regarding pediatric anatomy is correct?

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