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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

The correct answer is choice **b. Hearing loss**.

Choice A rationale:

Cataracts are not a common finding in newborns with congenital CMV infection. Cataracts are more commonly associated with other congenital infections like rubella, toxoplasmosis, and herpes simplex virus (HSV).

Choice B rationale:

Hearing loss is one of the most common manifestations of congenital CMV infection. Up to 40-58% of infants with symptomatic congenital CMV infection develop sensorineural hearing loss, which can be unilateral or bilateral, and progressive over time.

Choice C rationale:

Macrosomia, or large birth size, is not a typical finding in congenital CMV infection. In fact, infants with symptomatic congenital CMV infection are more likely to be small for gestational age or have intrauterine growth restriction.

Choice D rationale:

Urinary tract infection (UTI) is not a common presentation of congenital CMV infection. CMV can cause inclusion bodies in the urine, but overt UTI is not a typical finding. More common manifestations include petechiae, hepatosplenomegaly, jaundice, and central nervous system involvement.

A. Levothyroxine. B. Nifedipine. C. Chlorpromazine. D. Glyburide.

Correct Answer is D

Explanation

Choice A rationale:
Levothyroxine is not a medication used to treat gestational diabetes mellitus. Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism, which is a different medical condition.

Choice B rationale:
Nifedipine is a calcium channel blocker primarily used to manage hypertension and angina. It is not indicated for the treatment of gestational diabetes mellitus.

Choice C rationale:
Chlorpromazine is an antipsychotic medication used to treat conditions like schizophrenia and bipolar disorder. It has no role in the treatment of gestational diabetes mellitus.

Choice D rationale:
Glyburide is the correct medication to expect for administering to a client with gestational diabetes mellitus. Glyburide is an oral antidiabetic agent that helps lower blood glucose levels by increasing insulin secretion from the pancreas. It is often used when dietary and lifestyle modifications are not sufficient in managing gestational diabetes. However, it is essential to follow healthcare provider guidelines and closely monitor the client's blood glucose levels while on this medication. In some cases, insulin may be required if glyburide alone is inadequate in controlling blood sugar levels.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit?

Correct Answer is B

Explanation

A nurse is reviewing the medical record for a client who is receiving treatment for gestational diabetes mellitus. Which of the following medications should the nurse expect to administer?

Correct Answer is D

Explanation

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