NCLEX PN Practice Test Practice Question
While caring for a woman who delivered a healthy term infant six hours ago, the nurse notes that the fundus is soft, 2 cm above the umbilicus, and off to the left. The lochia is red. The nurse suspects that the client has which problem?
Correct Answer: C
Rationale: The scenario describes a soft fundus, elevated above the umbilicus, and shifted to the left, indicating potential urinary retention. When the bladder is distended, it can displace the uterus, leading to a soft fundus and increased risk of hemorrhage.
Option A, retained placental fragments, would typically present with a firm fundus and increased bleeding. Option B, perineal laceration, may cause bleeding but wouldn’t affect the fundal height or position significantly. Option D, normal involution, would show a firm fundus at or below the umbilicus, indicating the uterus is contracting appropriately.
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