A nurse is caring for a client who had a vaginal birth 4 hours ago and had a third-degree perineal laceration with repair.
The client has been unable to void since giving birth. Which of the following findings indicates the need for straight catheterization?
The client rates perineal pain as 3 on a scale of 0 to 10.
The client has a moderate amount of lochia rubra.
The client's perineum is ecchymotic with moderate edema.
The client's fundus is boggy and deviated to the right.
The Correct Answer is D
Choice A rationale
A pain rating of 3/10 indicates mild pain and is a expected finding following a vaginal birth with a third-degree laceration repair. Pain alone is not the primary indicator for catheterization unless it is severe enough to prevent voiding. The focus for catheterization is on signs of urinary retention and its consequences, like uterine atony.
Choice B rationale
Lochia rubra (bright red discharge, typically lasting 1-3 days) is the expected type of lochia 4 hours postpartum, and a moderate amount is normal. The characteristics of lochia are indicators of uterine involution and healing, but do not directly confirm the need for a catheterization due to inability to void.
Choice C rationale
Ecchymosis (bruising) and edema of the perineum are expected signs following a vaginal birth, especially with a laceration and repair. While swelling can sometimes contribute to difficulty voiding, it is an expected localized finding and not the most direct indicator that immediate straight catheterization is required to manage urinary retention.
Choice D rationale
A boggy (soft, not contracted) and deviated uterus is the most critical sign indicating a full or distended bladder preventing the uterus from contracting effectively. This distention leads to urinary retention and significantly increases the client's risk for postpartum hemorrhage. Immediate straight catheterization is necessary to empty the bladder and allow the uterus to firm up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Instructing the client to be NPO (nil per os), or nothing by mouth, is not typically required before an amniocentesis procedure. The client can usually eat and drink normally. Fasting is more commonly associated with procedures involving general anesthesia or those where there is a risk of aspiration, neither of which is routine for an amniocentesis. Clients may be asked to empty their bladder before the procedure to avoid puncturing it.
Choice B rationale
For an Rh-negative client undergoing an amniocentesis, there is a risk of fetomaternal hemorrhage during the procedure, which can lead to the mother's immune system producing Rh antibodies that attack the fetus's red blood cells in the current or future pregnancies. Therefore, administering Rh(D) immune globulin (RhoGAM) after the procedure is essential to prevent Rh sensitization. The standard dose is administered within 72 hours of the procedure.
Choice C rationale
Positioning the client in a left lateral position is typically used to promote optimal uteroplacental perfusion or during the second stage of labor. For an amniocentesis, the client is usually positioned in a supine position with a wedge placed under the right hip to slightly tilt the uterus and prevent vena cava compression, providing the provider with a clear anatomical view for ultrasound guidance.
Choice D rationale
The insertion site on the client's abdomen is cleaned with an antiseptic solution, such as povidone-iodine or chlorhexidine, to reduce the risk of introducing bacteria into the sterile field or uterus. Irrigating the site with sterile water is an inappropriate action for skin preparation as it is not a primary antiseptic and may interfere with the effectiveness of the chosen antiseptic solution.
Correct Answer is B
Explanation
Choice A rationale
Oxygen is typically administered for fetal distress or maternal hypoxemia, not routinely for pain management or epidural preparation. The priority before an epidural is often to stabilize maternal blood pressure, as the procedure frequently causes vasodilation and subsequent hypotension due to sympathetic blockade.
Choice B rationale
A key side effect of epidural anesthesia is hypotension caused by peripheral vasodilation from sympathetic nerve blockade. Administering a pre-procedure intravenous (IV) fluid bolus (e.g., normal saline or lactated Ringer's) increases circulating blood volume, effectively helping to minimize the risk and severity of this common hemodynamic change.
Choice C rationale
Ondansetron is a serotonin antagonist primarily used to treat nausea and vomiting. While sometimes used for these side effects in labor, it is not the priority action before an epidural. Fluid administration to prevent hypotension is the critical immediate prophylactic measure required for maternal safety.
Choice D rationale
While epidurals are commonly placed in the active phase of labor (usually 4 to 5 cm dilation or more), delaying the procedure until 7 cm is an outdated and arbitrary practice. The timing is determined by maternal request, pain level, and clinical assessment, not a rigid cervical dilation number, as effective pain relief is crucial.
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