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 C

Explanation

A. Catheterization may be necessary if the client cannot void but is not the first step before ambulation.
B. Evaluating deep tendon reflexes is more relevant for clients receiving magnesium sulfate, not primarily for epidural assessment.
C. Assessing motor function of the lower extremities ensures the client has adequate strength and sensation to safely ambulate after an epidural.
D. Administering meperidine is for pain management and does not relate to safety before ambulation.

A. Oral temperature 38.3 C (101 F ) B. HGB 10 g/dl (greater than 11 g/dl) C. Heart rate 98min D. Blood pressure 110/60 mm Hg E. Uterine contractions every 3 mins moderate to palpation

Correct Answer is ["A","B"]

Explanation

Oral temperature 38.3°C (101°F)
Elevated temperature indicates maternal fever, which could suggest infection such as chorioamnionitis, especially concerning with ruptured membranes.
HGB 10 g/dL (normal > 11 g/dL)
Low hemoglobin indicates anemia, which could compromise oxygen delivery to the fetus and affect maternal health during labor.

Explanation for non-highlighted findings:

Heart rate 98/min: Slightly elevated but within normal range for labor.
Blood pressure 112/59 mm Hg: Normal blood pressure for pregnancy.
Uterine contractions every 3 mins moderate to palpation: Normal pattern for active labor.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the fourth stage of labor and received an epidural during labor. Which of the following actions should the nurse take before ambulating the client to the bathroom?

Correct Answer is C

Explanation

Correct Answer is ["A","B"]

Explanation

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