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Maternity Evolve Exam, Exams of Nursing

Utah Valley University (UVU)Nursing

Prof. Weslie E. Sheldon

accelerations lasting less than 15 seconds throughout fetal movement.” The nurse interprets these findings as: Normal ⦁ Reactive Nonreactive Correct ⦁ Inconclusive

Typology: Exams

2023/2024

Available from 08/14/2023

Briantaller 🇺🇸

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•A nonstress test is performed, and the physician documents

“accelerations lasting less than 15 seconds throughout fetal

movement.” The nurse interprets these findings as:

•Normal

•Reactive

•Nonreactive Correct

•Inconclusive

Rationale: A reactive nonstress test is a normal, or negative, result and indicates a

healthy fetus. The result requires two or more fetal heart rate accelerations of at least

15 beats/min lasting at least 15 seconds from the beginning of the acceleration to the

end, in association with fetal movement, during a 20minute period. A nonreactive test

is an abnormal test, showing no accelerations or accelerations of less than 15

beats/min or lasting less than 15 seconds during a 40 minute observation. An

inconclusive result is one that cannot be interpreted because of the poor quality of the

fetal heart rate recording.

TestTaking Strategy: Use the process of elimination. Eliminate a reactive nonstress test

and a normal nonstress test first because they are comparable or alike. To select from

the remaining options, note the relationship between “less than 15 seconds” in the

question and “nonreactive” in the correct option. If you had difficulty answering this

question, review the interpretation of nonstress test results.

•A nurse caring for a client in labor performs an assessment. The client is

having consistent contractions less than 2 minutes apart. The fetal heart rate

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A nonstress test is performed, and the physician documents “accelerations lasting less than 15 seconds throughout fetal movement.” The nurse interprets these findings as: - Normal - Reactive - Nonreactive Correct - Inconclusive Rationale: A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus. The result requires two or more fetal heart rate accelerations of at least 15 beats/min lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20 minute period. A nonreactive test is an abnormal test, showing no accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds during a 40 minute observation. An inconclusive result is one that cannot be interpreted because of the poor quality of the fetal heart rate recording. TestTaking Strategy: Use the process of elimination. Eliminate a reactive nonstress test and a normal nonstress test first because they are comparable or alike. To select from the remaining options, note the relationship between “less than 15 seconds” in the question and “nonreactive” in the correct option. If you had difficulty answering this question, review the interpretation of nonstress test results.
A nurse caring for a client in labor performs an assessment. The client is having consistent contractions less than 2 minutes apart. The fetal heart rate

(FHR) is 170 beats/min, and fetal monitoring indicates a pattern of decreased variability. In light of these findings, the appropriate nursing action is:

- Contacting the physician Correct

Documenting the findings
Continuing to monitor the client
Reassuring the client and her partner that labor is progressing normally Rationale: Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer, contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia, persistently decreased variability, or an irregular FHR. The normal FHR is 110 to 160 beats/min. Therefore, because the finding is abnormal, the physician must be contacted. Continuing to monitor the client delays necessary intervention. Reassuring the client that labor is progressing normally is incorrect. The nurse would document the data, actions taken, and the client’s response, but, of the options provided, contacting the physician is the most appropriate. TestTaking Strategy: Use the process of elimination and focus on the data in the question. Eliminate the options that are comparable or alike and indicate that the data in the question are normal findings. Review normal assessment findings during the labor process if you had difficulty with this question.
A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate?
“I know how you feel.” - “This must be hard for you.” Correct
“Now you have an angel in heaven.”
“You’re young. You can have other children.” Rationale: Therapeutic communication helps the mother, father, and other family members express their feelings and emotions. “This must be hard for you” is a caring and empathetic response, focused on feelings and encouraging communication. The other options are nontherapeutic and may devalue the family members' feelings. TestTaking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only option that is focused on the family members’ feelings. Review therapeutic communication techniques if you had difficulty with this question.
A rubella antibody screen is performed in a pregnant client, and the results

A nurse provides instructions regarding postpartum exercises to a client who has delivered a newborn vaginally. The nurse tells the client that: - The exercises should be delayed for 1 month to allow healing - Performing such exercises in the postpartum period may result in stress urinary incontinence - Alternating contraction and relaxation of the muscles of the perineal area should be practiced Correct - Abdominal exercises will be started while the client is in the hospital as a means of evaluating tolerance
Rationale: Postpartum exercises may be started soon after birth, although the woman should be encouraged to begin with simple exercises and gradually progress to more strenuous ones. Abdominal exercises are postponed until approximately 4 weeks after a cesarean birth. Kegel exercises (alternated contraction and relaxation of the muscles of the perineal area) are extremely important in strengthening the muscle tone of the perineal area after vaginal birth. Kegel exercises help restore the muscle tone that is often lost as pelvic tissues are stretched and torn during pregnancy and birth. Women who maintain muscle strength may benefit years later, experiencing continued urinary continence.

TestTaking Strategy: Use the process of elimination. Note the relationship between the word “vaginally” in the question and “perineal area” in the correct option. Review the purpose and benefit of Kegel exercises if you had difficulty with this question. - A client in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal bleeding. Threatened abortion is suspected, and the nurse provides instructions to the client regarding care. Which statement by the client indicates the need for further instruction? - “I need to stay in bed for the rest of my pregnancy.” Correct - “I need to avoid having sex until the bleeding has stopped.”

“I need to watch for stuff that looks like tissue coming from my vagina.”
“I need to count the number of perineal pads that I use each day and make a note of the amount and color of blood on each pad.”
Rationale: Strict bed rest throughout the remainder of the pregnancy is not required. The woman is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding, as recommended by the physician or nursemidwife. The woman is instructed to count the perineal pads she uses each day and to note the quantity and color of blood on each pad. The woman should also watch for the evidence of the passage of tissue.

TestTaking Strategy: Use the process of elimination. Note the strategic words “need for further instruction” in the question, which indicate a negative event query and the need to select the incorrect client statement. Noting the words “stay in bed for the rest of my pregnancy” will direct you to this option. Review therapeutic management for threatened abortion if you had difficulty with this question. - A nurse is assessing the respiratory rate of a newborn. Which finding would the nurse document as normal?
20 breaths/min
25 breaths/min - 50 breaths/min Correct
70 breaths/min Rationale: The normal respiratory rate for a newborn infant is 30 to 60 breaths/min. All of the other options are outside the normal range. TestTaking Strategy: Knowledge regarding the normal respiratory rate of a newborn is required to answer this question. If you are unfamiliar with the normal ranges for newborn vital signs, review this content. - A nurse notes that the laboratory report of a pregnant client with suspected HIV infection indicates leukopenia, thrombocytopenia, anemia, and

A nurse provides information about the treatment for hypoglycemia to a client with gestational diabetes who will be taking insulin. The nurse tells the client that if signs and symptoms of hypoglycemia occur, she must immediately: - Incorrect
Lie down
Contact the physician - Correct
Drink 8 oz of diet soda
Check her blood glucose level Rationale: If signs and symptoms of hypoglycemia occur, the client should immediately check the blood glucose level. The results will determine the required treatment. If the blood glucose is less than 60 mg/dL, the client should immediately eat or drink something that contains 10 to 15 g of simple carbohydrate. Examples include a half cup (4 oz) of unsweetened fruit juice, a half cup (4 oz) of regular (not diet) soda, 5 or 6 LifeSavers candies, 1 tablespoon of honey or corn (Karo) syrup; 1 cup (8 oz) of milk; or 2 or 3 glucose tablets. The blood glucose is tested again 15 minutes after intake of the carbohydrate. If the glucose level is still below 60 mg/dL, the client should eat or drink another 10 to 15 g of simple carbohydrate. The blood glucose is tested once again 15 minutes after intake of the carbohydrate, and the physician is notified immediately if it is still below 60 mg/dL, because further intervention is necessary. Lying down will not increase the blood glucose level and will delay necessary intervention. TestTaking Strategy: Use the process of elimination and note the strategic word “immediately.” Remember that if hypoglycemia is suspected, a blood glucose test is needed to confirm its occurrence and then treatment measures must be taken immediately. Review the treatment measures for hypoglycemia if you had difficulty with this question.
A nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat?
Water and pretzels
Lowfat cheese omelet
Nachos and fried chicken - Apple and wholegrain toast Correct Rationale: The pregnant woman needs a wellbalanced diet high in iron and protein and adequate in calories for weight gain. Iron supplements that are taken during pregnancy tend to cause constipation. Constipation causes the client to strain during defecation, inadvertently performing the Valsalva maneuver, which causes blood to rush to the

heart and overload the cardiac system. The pregnant woman, then, should increase her intake of fluids and fiber. An unlimited intake of sodium (pretzels, cheese, nachos) could cause overload of the circulating blood volume and contribute to the cardiac condition. TestTaking Strategy: Use the process of elimination and note that the client has a history of cardiac disease. Recalling the concepts of care of the client with cardiac disease and noting that the question involves a client who is pregnant will direct you to the correct option. Review dietary requirements and examples of foods containing those requirements for a cardiac client who is pregnant if you had difficulty with this question.

A neonate is irritable, cries incessantly, and has a temperature of 99.4° F. The neonate is also tachypneic, diaphoretic, feeding poorly, and hyperactive in response to environmental stimuli. The nurse determines that these signs and symptoms are consistent with: - Sepsis - Hypercalcemia Incorrect - Intraventricular hemorrhage - Neonatal abstinence syndrome Correct Rationale: Neonatal abstinence syndrome is the term given to the group of signs and symptoms associated with drug withdrawal in the neonate. Drug withdrawal causes a hyperactive response in the infant because of the increased central nervous system (CNS) stimulation. This hyperactive response and the signs and symptoms of drug withdrawal seem to be most apparent around 1 week of age. Sepsis, hypercalcemia, and intraventricular hemorrhage cause symptoms of CNS depression. TestTaking Strategy: Use the process of elimination, focusing on the data in the question. Note the strategic word “hyperactive,” which indicates CNS stimulation and should direct you to the correct option. If you had difficulty with this question, review the signs and symptoms of drug withdrawal in the neonate.
A nurse is assisting a physician in performing a physical examination of a client who has just been told that she is pregnant. The physician tells the nurse that the Goodell sign is present. The nurse understands that this sign is indicative of:
The presence of fetal movement
A high risk for spontaneous abortion - An increase in vascularity and hyptertrophy of the cervix Correct - The presence of human chorionic gonadotropin (hCG) in the urine Incorrect

Rationale: After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel clots from the uterus. The nurse must also keep one hand pressed firmly just above the symphysis (over the lower uterine segment) the entire time. Removing the clots allows the uterus to contract properly. Providing pressure over the lower uterine segment prevents uterine inversion. Having the client void before uterine assessment will not prevent uterine inversion. Telling the woman to bear down while the nurse performs fundal message and asking the client to take slow, deep breaths during fundal assessment also will not prevent uterine inversion. TestTaking Strategy: Use the process of elimination, focusing on the subject, prevention of uterine inversion. Visualizing each of the actions in the options and relating the action to the subject of the question will direct you to the correct option. Review fundal assessment and massage if you had difficulty with this question.

A nurse assists a pregnant client who is in the second trimester into lithotomy position on the examining table in the obstetrician’s office. The client suddenly becomes dizzy, lightheaded, nauseated, and pale. The nurse immediately: - Positions the client on her side Correct - Calls the physician to see the client - Places a cool washcloth on the client’s forehead - Checks the client’s blood pressure, pulse, and respirations Rationale: Supine hypotension may occur during the second and third trimesters when a woman is placed in the lithotomy position, in which the weight of the abdominal contents may compress the vena cava and aorta, causing a drop in blood pressure and a feeling of faintness. Other signs and symptoms include pallor, dizziness, breathlessness, tachycardia, nausea, clammy (damp, cool) skin, and sweating. The nurse would immediately position the woman on her side. Placing a cool washcloth on the client’s forehead or checking the client’s vital signs will not eliminate this problem. The physician must be contacted if the symptoms do not subside, but this would not be the immediate action. TestTaking Strategy: Use the process of elimination and note the strategic word “immediately.” Focusing on the data in the question and determining that the client is experiencing supine hypotension will direct you to the correct option. Review the manifestations of supine hypotension and the interventions for treating this occurrence if you had difficulty with this question.
A nurse is monitoring a newborn who has been admitted to the nursery. The nurse notes that the anterior fontanel measures 4 cm across and bulges

when the infant is at rest. In light of this observation, what is the appropriate nursing action?

- Notifying the physician Correct

Documenting the finding
Assessing the infant’s blood pressure
Reassessing the fontanel in 30 minutes Rationale: The anterior fontanel, which is diamond shaped, is located on the top of the head. It should be flat and soft. It measures 1 to 4 cm, varying as a result of molding and individual differences. It normally closes by 12 to 18 months of age. Although the anterior fontanel may bulge slightly when the infant cries, bulging at rest may indicate increased intracranial pressure. If this is suspected, the physician is notified. The other options would delay necessary treatment. TestTaking Strategy: Use the process of elimination and note the strategic words “bulges when the infant is at rest.” Recalling that the fontanel should be soft and flat will direct you to the correct option. Review normal newborn assessment findings if you had difficulty with this question.
A nurse midwife performs an assessment of a pregnant client and documents the station of the fetal head as it is reflected in the figure below. The nurse reviews the assessment findings and determines that the fetal presenting part is:
At +1 station
At –1 station - At zero station Correct
Stationed at the bottom of the coccyx Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. It is measured in centimeters and is noted as a negative number above the line, a positive number below the line, and zero at the line. TestTaking Strategy: Knowing that station is measured in centimeters, with the ischial spines as a reference point, will assist you in answering this question. Focus on the figure and note that the fetal head is at zero station. Review station if you had difficulty with this question.
A client is admitted to the hospital for an emergency cesarean delivery. Contractions are occurring every 15 minutes, the client has a temperature of 100° F, and the client reports that she last ate 2 hours ago. The client also states that “everything happened so fast" and that she has had no preparation for the

A nurse is monitoring a client in the third trimester of pregnancy who has a diagnosis of severe preeclampsia. Which finding would prompt the nurse to contact the physician? - Complaint of feeling hot - Enlargement of the breasts - Diaphoresis and tachycardia Correct - Periods of fetal movement followed by quiet periods Rationale: Disseminated intravascular coagulation (DIC) is a complication of preeclampsia. Physical examination reveals unusual bleeding, spontaneous bleeding from the woman’s gums or nose, or the presence of petechiae around a blood pressure cuff placed on the woman’s arm. Excessive bleeding may occur from a site of slight trauma such as a venipuncture site, an intramuscular or subcutaneous injection site, a nick sustained during shaving of the perineum or abdomen, or injury inflicted during insertion of a urinary catheter. Tachycardia and diaphoresis indicate impending shock as a result of blood loss. Breast enlargement, fetal movement with rest periods, and complaints of feeling hot are all normal occurrences in the last trimester of pregnancy. TestTaking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they are normal occurrences in pregnancy. Review the complications associated with severe preeclampsia if you had difficulty with this question.
A nurse is monitoring a pregnant client with sepsis for signs of disseminated intravascular coagulopathy (DIC). Which of the following laboratory findings causes the nurse to suspect DIC?
Increased platelet count
Increased fibrinogen level
Shortened prothrombin time - Increased fibrin degradation products Correct Rationale: DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Petechiae, oozing from injection sites, and hematuria are indicative of DIC. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and therefore prolonged times); and fibrin plugs
A nurse is caring for a client experiencing hypotonic labor contractions. The client is discouraged by the lack of progress with labor but refuses an amniotomy or oxytocin (Pitocin) stimulation. The nurse determines that the

client’s behavior may be a result of:

- Concern about her own and the baby’s wellbeing Correct

The high level of pain caused by these contractions
Inability to rest between the frequent contractions
The normal lack of control clients feel during the transition phase of labor Rationale: Clients have concerns when labor does not proceed as expected and often are worried about the effects of treatments and invasive procedures on themselves and on the fetus. Hypotonic contractions generally occur during the active phase of labor, after a normal latent phase. These contractions are typically of poor intensity and infrequent; they are not painful but cause a very slow progression of labor. Therefore the high level of pain, inability to rest between contractions, and normal lack of control felt during the transition phase of labor are all incorrect. TestTaking Strategy: Use the process of elimination, focusing on the subject, hypotonic labor contractions. Thinking about the pathophysiology of hypotonic labor will direct you to the correct option. Also, noting that the client is refusing treatments will assist you in answering correctly. Review the characteristics of hypotonic labor contractions and the psychosocial reactions associated with this disorder if you had difficulty with this question.
A woman with severe preeclampsia delivers a healthy newborn infant and continues to receive magnesium sulfate therapy in the postpartum period. Twentyfour hours after delivery, the client begins passing more than 100 mL of urine every hour. The nurse recognizes this volume of urine output as an indication of:
Imminent seizures
Hyperkalemia
Highoutput renal failure - Diminished edema and vasoconstriction in the brain and kidneys Correct Rationale: In this client, diuresis is a positive sign, indicating that edema and vasoconstriction in the brain and kidneys have decreased. Diuresis also reflects increased tissue perfusion in the kidneys. Clients with severe preeclampsia are not considered out of danger until birth and diuresis have taken place. Diuresis is not an indication of impending seizures. Although renal failure is a complication of severe preeclampsia, it is not the highoutput type of failure. Potassium is lost through the urine; therefore hyperkalemia is not associated with diuresis.

TestTaking Strategy: Knowledge regarding the therapeutic management of the mother with tuberculosis and that of the infant is required to answer this question. Eliminate the options containing the closedended words “must,” “not,” and “immediately.” If you had difficulty with this question, review treatment measures for the mother with tuberculosis. - A nurse is performing an assessment of a client who is at 20 weeks of gestation. The nurse asks the client to void, then measures the fundal height in centimeters. Which approximate measurement does the nurse expect to see? - 20 cm Correct - 28 cm - 32 cm - 40 cm Rationale: During the second and third trimesters (weeks 18 to 30), the height of the fundus in centimeters is approximately the same as the number of weeks of gestation, if the woman’s bladder is empty at the time of measurement. If the fundal height exceeds the number of weeks of gestation, additional assessment is necessary to investigate the cause for the unexpectedly large uterine size. An unexpected increase in uterine size may indicate that the estimated date of delivery is incorrect and the pregnancy is more advanced than previously thought. If the estimated date of delivery is correct, more than one fetus may be present. TestTaking Strategy: Knowledge regarding the expected findings in fundal height during the second or third trimester is required to answer this question. Remember that the height of the fundus in centimeters during the second and third trimesters is approximately the same as the number of weeks of gestation. If you are unfamiliar with the interpretation of fundal height, review this content. - A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal discharge. The nurse tells the client: - To perform a vaginal douche - To come to the clinic for a checkup - That this is an indication of an infection - That this is a normal postpartum occurrence Correct - A nurse is caring for a client receiving an intravenous infusion of oxytocin

(Pitocin) to stimulate labor. Which of the following findings would prompt the nurse to stop the infusion?

Contractions every 3 minutes - Nonreassuring fetal heart rate pattern Correct
Soft uterine tone palpated between contractions
The presence of three contractions every 10 minutes Rationale: The goal of labor augmentation is to achieve three goodquality contractions (of appropriate intensity and duration) in a 10 minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress. If a nonreassuring fetal heart rate pattern is detected, the oxytocin infusion is stopped. A nonreassuring fetal heart rate pattern is associated with fetal hypoxia. TestTaking Strategy: Use the process of elimination and your knowledge of the ABCs (airway, breathing, and circulation). Eliminate the options that are comparable or alike (i.e., contractions every 3 minutes and occurrence of three contractions every 10 minutes). The correct option, of the two that remain, is the one that indicates a problem with circulation. Review the expected outcomes and the signs of complications associated with oxytocin infusion if you had difficulty with this question.
A nurse assessing a pregnant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which of the following situations would the nurse suspect in light of this observation?
Umbilical cord compression - Pressure on the fetal head during a contraction Correct
Adequate pacemaker activity of the fetal heart
Uteroplacental insufficiency during a contraction Rationale: Early decelerations, which result from pressure on the fetal head during a contraction, are not associated with fetal compromise and require no intervention. Variable decelerations suggest umbilical cord compression. Late decelerations are an ominous pattern in labor because they suggest uteroplacental insufficiency during a contraction. "Shortterm variability" refers to the difference between successive heartbeats, indicating that the natural pacemaker activity of the fetal heart is working properly. TestTaking Strategy: The ability to interpret and evaluate fetal monitoring patterns is required to answer this question. Relate early decelerations to pressure on the fetal head during a contraction to assist in answering questions similar to this one. If you are unfamiliar with early decelerations and their significance, review this content.
A delivery room nurse performing an initial assessment on a newborn

who is receiving magnesium sulfate for preeclampsia. Which of the following findings would prompt the nurse to contact the physician?

Urine output of 20 mL
Deep tendon reflexes of 2+ - Respirations of 10 breaths/min Correct
Fetal heart tone of 116 beats/min Rationale: Magnesium sulfate depresses the respiratory rate. If the rate is 12 breaths/min or slower, continuation of the medication must be reassessed. Acceptable urine output is 30 mL/hr or more. Urine output of 20 mL in 30 minutes is adequate. Deep tendon reflexes of 2+ are normal. The fetal heart tone is within normal limits for a resting fetus. TestTaking Strategy: Note the strategic words “contact the physician.” Use the process of elimination, noting the
A nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. The nurse tells the mother to:
Take a cool shower just before breastfeeding
Avoid breastfeeding during the night time hours to ensure adequate rest - Gently massage the breasts during breastfeeding to help empty the breasts Correct
Apply heat packs to the breasts for 15 to 20 minutes between feedings to reduce swelling Rationale: Gently massaging the breasts during breast feeding will help empty the breasts. The mother should not avoid breastfeeding during the night; instead, she should breastfeed every 2 hours or pump the breasts. The nurse instructs the woman to apply ice packs, not heat packs, to the breasts between feedings to reduce swelling. It may be helpful for the mother to stand in a warm shower just before feeding to foster relaxation and letdown. TestTaking Strategy: Focus on the subject, breast engorgement, and think about its characteristics. Use the process of elimination and visualize each of the descriptions in the options to identify the measure that will be helpful. If you had difficulty answering the question, review the measures for breast engorgement.
A nurse is caring for a postpartum client who had a lowlying placenta. The

nurse assesses the client most closely for:

Seizures
Infection - Hemorrhage Correct
A vaginal hematoma Rationale: The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, making this site more prone to bleeding. The client with a lowlying placenta is not at greater risk for seizures, postpartum infection, or vaginal hematoma. TestTaking Strategy: Focus on the client’s diagnosis, a lowlying placenta. Recalling the anatomy and physiology of the lower segment of the uterus will direct you to the correct option. Review the complications associated with a lowlying placenta if you had difficulty with this question.
When, during the normal postpartum course, would the nurse expect to note the fundal assessment shown in the figure?
4 days after delivery
The day after delivery - Immediately after delivery Correct
When the client’s bladder is full Rationale: Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. Location of the fundus above the umbilicus may indicate the presence of blood clots in the uterus that need to be expelled by means of fundal massage. A fundus that is not located in the midline may indicate a full bladder. The fundus descends 1 or 2 cm every 24 hours, so it should be located farther below the umbilicus with every succeeding postpartum day. TestTaking Strategy: Focus on the figure and note that the fundus is at the level of the umbilicus. Recalling normal postpartum assessment findings in the mother and recalling the normal anatomy will assist in directing you to the correct option. If you had difficulty with this question, review normal postpartum assessment findings in regard to involution.
A nurse is caring for a client in labor who has sickle cell anemia. Which intervention does the nurse implement to help prevent a sickling crisis?

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