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?

Moderate swelling of the labia

Fundus three fingerbreadths above the umbilicus

Moderate lochia rubra

Blood pressure 130/84 mm Hg

Answer and Explanation

The Correct Answer is B

Choice B reason:
A fundus that is elevated and displaced from the midline indicates a full bladder, which can interfere with uterine contraction and increase the risk of hemorrhage. The nurse should assist the client to void or catheterize her if necessary.

Choice A reason:
Moderate swelling of the labia is a normal finding after vaginal delivery, and does not indicate a need to urinate. The nurse should apply ice packs and perineal pads to reduce edema and discomfort.

Choice C reason:
Moderate lochia rubra is a normal finding during the first 24 hr postpartum, and does not indicate a need to urinate. The nurse should monitor the amount and color of lochia, and change the perineal pads as needed.

Choice D reason:
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum client, and does not indicate a need to urinate. The nurse should monitor the blood pressure for signs of hypertension or hypotension, which can indicate complications such as preeclampsia or hemorrhage.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason:

A warm sitz bath can promote healing and comfort, but it is not recommended until 24 hr after delivery, as it can increase swelling and bleeding.

Choice B reason:

An ice pack can reduce inﬂammation and pain by causing vasoconstriction and numbing the area. It should be applied for 20 minutes at a time, with a cloth barrier between the skin and the ice.

Choice C reason:

A soft pillow under the client's butocks can increase pressure on the perineum and worsen the pain. The client should be encouraged to lie on her side or sit in a semi-Fowler's position.

Choice D reason:

A heating lamp can dry out the wound and delay healing. It can also cause burns and discomfort. It should be avoided for episiotomy care.

A. Fundus soft, 2 fingerbreadths below the umbilicus B. Fundus firm, 1 fingerbreadth below the umbilicus C. Fundus firm, 4 fingerbreadths above the umbilicus D. Fundus soft, to the right of the umbilicus

Correct Answer is B

Explanation

Choice A reason: Fundus soft, 2 fingerbreadths below the umbilicus is incorrect, as this finding indicates uterine atony and subinvolution. The fundus is the upper part of the uterus that can be palpated through the abdomen after birth. The fundus should be firm and midline to indicate adequate uterine contraction and involution. A soft or boggy fundus can increase the risk of hemorrhage and infection.

Choice B reason: Fundus firm, 1 fingerbreadth below the umbilicus is correct, as this finding indicates normal uterine contraction and involution. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one fingerbreadth per day. A firm and midline fundus can prevent excessive bleeding and promote healing.

Choice C reason: Fundus firm, 4 fingerbreadths above the umbilicus is incorrect, as this finding indicates a higher than expected fundal height for a client who is 24 hr postpartum. The fundus is normally at the level of the umbilicus immediately after birth and then descends about one fingerbreadth per day. A high fundal height can indicate uterine atony, retained placental fragments, or bladder distension.

Choice D reason: Fundus soft, to the right of the umbilicus is incorrect, as this finding indicates uterine atony and bladder distension. The fundus should be firm and midline to indicate adequate uterine contraction and involution. A deviated fundus can indicate bladder distension, which can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is 24 hr postpartum. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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 nurse is assisting in the care of a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

A nurse is assisting with the care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate eﬀectiveness of this medication?

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hours ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has a history of genital herpes. Which of the following actions should the nurse take?

A nurse is collecting data from a postpartum client and notes the client's fundus is boggy and displaced to the right. Which of the following actions should the nurse take?