A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?
Offer the client a sitz bath.
Insert a urinary catheter.
Assist the client to the bathroom.
Pour warm water over the client's perineum.
The Correct Answer is C
Choice A rationale:
Offering the client a sitz bath may provide some relief, but it does not address the underlying issue of bladder distention. The priority is to address the bladder distention directly.
Choice B rationale:
Inserting a urinary catheter is not the first-line intervention for bladder distention after vaginal birth. Catheterization carries a risk of infection and trauma, so it should only be done if other interventions are not effective.
Choice C rationale:
Assisting the client to the bathroom is the first action the nurse should take. Bladder distention can occur after birth due to the pressure on the bladder during labour and birth. Encouraging the client to empty her bladder will relieve the distention and promote comfort.
Choice D rationale:
Pouring warm water over the client's perineum might provide some comfort, but it does not address the bladder distention itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Oatmeal is a good source of fibre, but its fibre content per cup is not as high as some other options.
Choice B rationale:
Cabbage is a healthy choice with some fibre content, but it does not have as much fibre per cup as lentils.
Choice C rationale:
Lentils have the highest fibre content per cup compared to the other options listed. They are rich in both soluble and insoluble fibre, which helps promote bowel regularity and alleviate constipation.
Choice D rationale:
Asparagus is a nutritious vegetable but does not have as much fibre per cup as lentils.
Correct Answer is A
Explanation
The correct answer is choice A, administer broad-spectrum antibiotics.
Choice A rationale:
Administering broad-spectrum antibiotics is crucial for a newborn with a myelomeningocele that is leaking cerebrospinal fluid to prevent infection. The leaking of cerebrospinal fluid can increase the risk of meningitis, which is an infection of the membranes covering the brain and spinal cord. Broad-spectrum antibiotics are used as a prophylactic measure to reduce this risk.
Choice B rationale:
Monitoring the rectal temperature every 4 hours is important for detecting fever, which could indicate infection. However, it is not the most immediate action required for a newborn with a leaking myelomeningocele. The priority is to prevent infection through the administration of antibiotics.
Choice C rationale:
Cleansing the site with povidone-iodine is not recommended for a myelomeningocele because it can be toxic to the exposed neural tissue. Instead, the area should be covered with a sterile saline dressing to protect the site and prevent drying and further damage to the neural tissue.
Choice D rationale:
While surgical closure is necessary for a newborn with myelomeningocele, it is typically performed within 24 to 48 hours after birth, not after 72 hours. Early closure is essential to reduce the risk of infection and further damage to the exposed spinal cord and nerves.
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