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

Answer and Explanation

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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Correct Answer is B

Explanation

A. While bilirubin levels are important, the immediate concern for a large-for-gestational-age (LGA) newborn is hypoglycemia.
B. LGA newborns are at increased risk for hypoglycemia, so monitoring blood glucose levels is essential.
C. Arterial blood gases are not routinely indicated unless respiratory distress is present.
D. WBC count is not specifically related to LGA status.

A. Nausea B. Persistent headaches C. Breast tenderness D. Abdominal bloating

Correct Answer is B

Explanation

A. Nausea is a common and generally mild side effect of oral contraceptives and does not typically require immediate medical attention.
B. Persistent headaches may indicate an increased risk of stroke or hypertension, especially in clients with other risk factors. This could be a sign of a serious adverse effect and should be reported to the provider immediately.
C. Breast tenderness is a common and usually benign side effect of hormonal contraceptives.
D. Abdominal bloating may occur but is not typically dangerous or an urgent concern.

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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?

Nursing Test Bank

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