A nurse is assessing a client who is 8 hours postpartum and multiparous.
Which of the following findings should alert the nurse to the client’s need to urinate?
Fundus three fingerbreadths above the umbilicus
Blood pressure 130/84 mm Hg
Moderate lochia rubra
Moderate swelling of the labia
The Correct Answer is D
Choice A rationale:
The location of the fundus is not a reliable indicator of urinary retention. The fundus may be displaced upward by a full
bladder, but it can also be displaced by other factors such as uterine atony or a full rectum.
In the early postpartum period, the fundus is expected to be firm and around 1-2 fingerbreadths below the umbilicus. A fundus
that is three fingerbreadths above the umbilicus may be a sign of uterine atony, but it is not specifically indicative of urinary
retention.
Choice B rationale:
Blood pressure is not a specific indicator of urinary retention. A blood pressure of 130/84 mm Hg is within the normal range
for a postpartum client.
Elevated blood pressure could be due to various factors, such as pain, anxiety, or pre-existing hypertension. It is not a reliable
sign of urinary retention on its own.
Choice C rationale:
Lochia rubra is the normal postpartum discharge that consists of blood, mucus, and tissue debris. The amount of lochia rubra
is expected to decrease gradually over time. Moderate lochia rubra is a normal finding in a client who is 8 hours postpartum
and does not suggest urinary retention.
Choice D rationale:
Moderate swelling of the labia is a common finding in the postpartum period due to increased blood flow and fluid retention.
However, significant swelling of the labia can also be a sign of urinary retention.
When the bladder is full, it can press on the surrounding tissues, including the labia, causing them to swell. If the client is also
experiencing difficulty voiding or has a decreased urine output, the swelling of the labia may be a sign that she needs to
urinate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
During the taking-in phase, which typically lasts 2-3 days postpartum, the client's primary focus is on herself and her own
needs. She may be physically exhausted and emotionally overwhelmed by the birthing experience.
Interest in learning about newborn care is more characteristic of the taking-hold phase, which begins around the third day
postpartum.
Choice B rationale:
Concerns about managing at home are more likely to arise during the letting-go phase, which begins around the fourth week
postpartum.
During this phase, the mother is adjusting to her new role and responsibilities, and she may feel anxious about her ability to
care for her baby on her own.
Choice C rationale:
While some mothers may be eager to share their birth stories during the taking-in phase, it is not a universal characteristic of
this phase.
Many mothers are still processing their experiences and may not be ready to talk about them in detail.
Choice D rationale:
The focus on personal needs and recovery is a hallmark of the taking-in phase.
The mother is typically preoccupied with physical comfort, rest, and nourishment.
She may also be emotionally labile, experiencing a range of emotions from euphoria to sadness.
Correct Answer is B
Explanation
Choice A rationale:
Pushing continuously throughout the entire contraction can lead to maternal exhaustion and may not be the most effective way to progress labor. It’s important for the mother to conserve her energy and work with her body’s natural rhythms.
Choice B rationale:
Taking a deep, cleansing breath before and after each contraction can help the mother manage pain and keep her energy up.
This technique is often recommended because it allows the mother to rest briefly and gather strength for the next contraction.
Choice C rationale:
While it’s important for the nurse to monitor contractions and provide guidance, the urge to push is a natural response that
can vary among individuals. Telling the mother when to push according to contractions may not align with her body’s natural
instincts.
Choice D rationale:
Holding one’s breath and pushing while someone counts to ten is an outdated practice. This method can cause unnecessary
strain and doesn’t take into account the individual rhythms and responses of the mother’s body.
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