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 C
Explanation
Choice A rationale
Docusate sodium is a stool softener and is not contraindicated for a postpartum client with a 4th degree laceration.
Choice B rationale
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can be safely used postpartum for pain management.
Choice C rationale
Carboprost is a medication used to control postpartum hemorrhage but is contraindicated in clients with asthma and with other risk factors due to its side effects, including severe diarrhea.
Choice D rationale
Ferrous sulfate is used to treat anemia and is not contraindicated in a postpartum client with a 4th degree laceration.
Correct Answer is D
Explanation
Choice A rationale
Placing the patient in a Trendelenburg position is not the immediate priority. This position is often used to manage shock or to improve blood flow to the brain, but it does not directly address the cause of heavy lochia. It may not be the most effective first intervention in this situation.
Choice B rationale
Notifying the physician is important, but the nurse should first attempt to control the bleeding. The physician can be notified after initial measures to stop the bleeding are taken. Immediate intervention by the nurse is crucial in this scenario to stabilize the patient.
Choice C rationale
Administering Methylergonovine can help control postpartum hemorrhage, but this should be done after attempting non-pharmacological measures like fundal massage. Methylergonovine can have side effects and should be used with caution.
Choice D rationale
Massaging the fundus until it is firm is the immediate priority. This can help expel clots and stimulate uterine contraction, which can reduce bleeding. It is a direct and immediate intervention to address the heavy lochia.
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.