A nurse is caring for a client who had a vaginal birth 4 hr ago and had a 3rd-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 a 3 on a scale of 0 to 10.
The client's fundus is boggy and deviated to the right
The client has a moderate amount of lochia rubra
The client's perineum is ecchymotic with moderate edema
The Correct Answer is B
A. A pain rating of 3 is relatively mild and does not indicate urinary retention.
B. A boggy, deviated fundus suggests bladder distention, which can occur when the bladder is full and displaces the uterus. This is an indication for straight catheterization to relieve urinary retention.
C. Moderate lochia rubra is expected 4 hours postpartum and does not indicate urinary retention.
D. While edema and bruising are common after delivery, they do not alone indicate a need for catheterization.
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Related Questions
Correct Answer is ["A","E"]
Explanation
A. Inactivated influenza vaccine is safe and recommended during pregnancy to protect both mother and fetus.
B. Human papillomavirus (HPV) vaccine is not recommended during pregnancy.
C. Measles, mumps, and rubella (MMR) vaccine is a live vaccine and contraindicated during pregnancy.
D. Varicella vaccine is live and contraindicated during pregnancy.
E. The Tdap vaccine (diphtheria, acellular pertussis, tetanus) is recommended during each pregnancy, ideally between 27 and 36 weeks gestation to protect the newborn from pertussis.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"}}
Explanation
- Administer an iron supplement: The client has low hemoglobin, hematocrit, RBCs, and ferritin, which are consistent with iron deficiency anemia. Iron supplementation is expected to help correct the deficiency and improve oxygen-carrying capacity.
- Refer for a nutritional consult: A vegan diet, if not properly planned, can lack adequate sources of iron and vitamin B12. A nutritionist can help the client meet dietary needs through fortified foods or supplements, addressing underlying causes of anemia.
- Place the client on a low sodium diet: The client’s blood pressure is within acceptable range, and there is no history of hypertension or fluid overload. A low sodium diet would not target the client’s current symptoms of anemia and fatigue.
- Restrict fluid intake: The client shows signs of volume depletion (orthostatic hypotension and low Hct) rather than fluid overload. Restricting fluids could worsen hypotension and contribute to decreased perfusion, making it inappropriate.
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