A nurse is assessing a client postpartum.Which of the following findings should alert the nurse to the client's need to urinate?
Large amount of swelling of the labia.
Fundus three fingerbreadths above the umbilicus.
Moderate lochia rubra.
Swelling of the ankles and feet.
The Correct Answer is B
Choice A rationale
Swelling of the labia postpartum can be a common occurrence due to trauma during delivery and does not specifically indicate the need to urinate. The swelling usually subsides with time and proper postpartum care.
Choice B rationale
A fundus positioned three fingerbreadths above the umbilicus can indicate a full bladder. The bladder's distension prevents the uterus from contracting properly, which can lead to postpartum hemorrhage and other complications, hence the need for the client to urinate.
Choice C rationale
Moderate lochia rubra is a normal finding in the postpartum period and does not specifically indicate the need to urinate. Lochia changes in color and amount over the postpartum weeks as the uterus heals.
Choice D rationale
Swelling of the ankles and feet, or edema, is common postpartum due to the body's adjustment to changes in blood volume and fluid shifts. It does not directly indicate the need to urinate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Clear fluid oozing from a pilonidal sinus is unrelated to congenital hip dysplasia and more associated with other conditions like pilonidal cysts.
Choice B rationale
A positive hip click can indicate hip instability but is not definitive for congenital hip dysplasia.
Choice C rationale
Erythema toxicum is a benign, self-limiting skin condition and does not relate to hip dysplasia.
Choice D rationale
Limited abduction of the hip is a key sign of congenital hip dysplasia, indicating restricted movement due to abnormal hip joint development. .
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
A red, tender area on the breast could indicate mastitis, an infection of the breast tissue. This requires prompt medical attention to prevent complications and provide appropriate treatment, often involving antibiotics.
Choice B rationale
A temperature of 100.8°F is considered a fever and could indicate an infection. Postpartum clients are at risk of infections, including endometritis, and should report any fever to their healthcare provider for further evaluation.
Choice C rationale
Burning on urination could indicate a urinary tract infection (UTI). UTIs are common postpartum due to catheter use and trauma during delivery. This symptom should be reported for evaluation and treatment if necessary.
Choice D rationale
Increased lochia rubra can indicate postpartum hemorrhage or retained placental fragments. Any significant change in bleeding pattern should be reported to ensure timely management and prevent serious complications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.