Nokea
Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which of the following?
- A. Prolonged first stage of labor.
- B. Urinary tract infection.
- C. Pressure of the uterus on the bladder.
- D. Edema in the lower urinary tract area.
Correct Answer: D
Rationale: Edema in the lower urinary tract, often from delivery trauma or epidural anesthesia, can cause urinary retention and bladder distention.
You may also like to solve these questions
A client who had a cesarean delivery 24 hours ago complains of pain from abdominal distention. The client has been on nothing-by-mouth status for the past 36 hours. The nurse should:
- A. Offer the client a carbonated beverage twice daily.
- B. Tell the client to use a straw when drinking fluids.
- C. Limit the client to a soft diet until more bowel sounds exist.
- D. Encourage ambulation in the hallway.
Correct Answer: D
Rationale: Ambulation promotes bowel motility, relieving abdominal distention.
A primigravid client at 34 weeks' gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client's vital signs, the client says, "I think my bag of water just broke." Which of the following would the nurse do first?
- A. Check the status of the fetal heart rate.
- B. Turn the client to her right side.
- C. Test the leaking fluid with nitrazine paper.
- D. Perform a sterile vaginal examination.
Correct Answer: A
Rationale: Checking the fetal heart rate is the first action to ensure fetal well-being.
A neonate with heart failure is being discharged home. In teaching the parents about the neonate's nutritional needs, the nurse should explain that:
- A. Fluids should be restricted.
- B. Decreased activity level should reduce the need to additional reduces.
- C. The formula should be low in sodium.
- D. The neonate may need a formula with higher calories per fluid ounce.
Correct Answer: D
Rationale: A neonate with heart failure may require a higher-calorie formula to meet energy needs without increasing fluid volume.
The physician determines that outlet forceps are needed to assist in the delivery of a primigravid client in active labor with a large-for-gestational-size fetus. The nurse reinforces the physician's explanation for using forceps based on the understanding about which of the following concerning the location of the fetus?
- A. Fetal head at the pelvic outlet.
- B. Fetal head at the ischial spines.
- C. Fetal head above the pelvic brim.
- D. Fetal head in the false pelvis.
Correct Answer: A
Rationale: Outlet forceps are used when the fetal head is at the pelvic outlet, visible at the perineum, allowing safe assisted delivery. Higher fetal positions require different interventions.
A nurse is counseling a client about the use of barrier methods. Which of the following client statements indicates a need for further teaching?
- A. I will use a new condom for each act of intercourse.
- B. The diaphragm should be left in place for at least 6 hours after intercourse.
- C. The cervical cap can be used without spermicide.
- D. I will check the condom for tears before use.
Correct Answer: C
Rationale: The cervical cap requires spermicide for effectiveness, indicating a need for further teaching. The other statements are correct regarding condom use and diaphragm care.