Nokea
A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate?
- A. Moderate lochia rubra
- B. Fundus three fingerbreadths above the umbilicus
- C. Moderate swelling of the labia
- D. Blood pressure 130/84 mm Hg
Correct Answer: B
Rationale: A fundus three fingerbreadths above the umbilicus indicates that the uterus is not adequately contracting, which can obstruct the flow of urine from the bladder. Postpartum clients often experience urinary retention due to decreased sensation in the bladder, trauma from delivery, and decreased bladder tone. Failure to empty the bladder promptly can lead to urinary retention and potential complications such as urinary tract infections or bladder distention. Therefore, the nurse should be alert to the client's need to urinate when assessing the fundal height.
You may also like to solve these questions
Relaxation of muscles in labor provides many benefits. What is one benefit of this technique in labor?
- A. Relaxation will prevent a cesarean section.
- B. Relaxation of the pelvic floor helps in pushing the fetus in the second stage.
- C. Relaxation of the abdomen ensures an unmedicated birth.
- D. Relaxation causes the contractions to decrease in strength.
Correct Answer: B
Rationale: Relaxing the pelvic floor facilitates smoother fetal descent during the second stage of labor.
A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications?
- A. Hyperemesis
- B. Proteinuria
- C. Hypoxia
- D. Hemorrhage
Correct Answer: D
Rationale: Following an amniocentesis, the nurse should observe the client for the potential complication of hemorrhage. Amniocentesis is a procedure where a small amount of amniotic fluid is extracted from the amniotic sac surrounding the fetus for various diagnostic purposes. The risk of hemorrhage is associated with this invasive procedure due to the possibility of damaging blood vessels within the uterus during the insertion of the needle. It is important for the nurse to closely monitor the client for any signs of bleeding, such as vaginal bleeding, abdominal pain, or signs of shock, and report any concerns promptly to the healthcare provider for further evaluation and management.
The nurse is reviewing a copy of the U.S. Surgeon General's Report, Healthy People 2020. Which nursing action best reflects the nurse fostering this health care agenda?
- A. The nurse signs up for classes to obtain an advanced degree in nursing.
- B. The nurse volunteers at a local health care clinic providing free vaccinations for low-income populations.
- C. The nurse performs an in-service on basic hospital equipment for student nurses.
- D. The nurse compiles nursing articles on evidence-based practices in nursing to present at a hospital training seminar.
Correct Answer: B
Rationale: Healthy People 2020 is a comprehensive health promotion and disease prevention agenda that is working toward improving the quantity and quality of life for all Americans.
For which condition should the nurse immediately
- A. Applying her peri-pad from back to front with notify the health care team?
- B. Periodic breathing in the newborn lasting
- C. Using the peri-bottle to rinse her perineum after approximately 3 to 5 seconds
- D. Blood sugar recording of 60 mg/dL in an infant born 6 hours ago
Correct Answer: D
Rationale: A blood sugar recording of 60 mg/dL in an infant born 6 hours ago requires immediate notification of the health care team. This low blood sugar level, also known as hypoglycemia, is a critical concern in newborns as it can lead to serious complications if not promptly addressed. Infants are particularly vulnerable to hypoglycemia due to their limited glycogen stores and high metabolic demands, which can result in inadequate glucose production. Immediate intervention and close monitoring by the healthcare team are essential to prevent potential long-term neurological consequences associated with hypoglycemia in newborns.
Before discharge, what health teaching should the nurse provide to a woman diagnosed with pelvic inflammatory disease (PID)?
- A. Endometriosis.
- B. Menopause.
- C. Ovarian hyperstimulation.
- D. Sexually transmitted infections.
Correct Answer: D
Rationale: PID is often caused by untreated STIs, so education about STIs is crucial.