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

Choice A rationale:

Amniotic fluid embolism is a rare but serious complication during labor or immediately after delivery, where amniotic fluid, fetal cells, hair, or other debris enter the mother's bloodstream and cause a severe reaction. While it may present with sudden and severe symptoms, such as hypotension and respiratory distress, it does not typically cause uterine rupture.

Choice B rationale:

Uterine rupture is a life-threatening emergency that can occur during labor, especially in women with previous uterine surgeries or trauma. The sudden, severe lower abdominal pain, drop in blood pressure, cool skin, and pallor could indicate internal bleeding and shock, which are consistent with uterine rupture. Prolonged bradycardia on the fetal heart rate tracing suggests fetal distress due to compromised blood flow.

Choice C rationale:

Umbilical cord prolapse is another obstetric emergency that occurs when the umbilical cord slips through the cervix and gets compressed during labor, leading to fetal distress. It may cause variable decelerations in fetal heart rate, but it does not explain the maternal symptoms described in the scenario, such as the sudden, severe lower abdominal pain, hypotension, cool skin, and pallor.

Choice D rationale:

Placenta previa is a condition where the placenta covers part or all of the cervix, and it can lead to painless vaginal bleeding. While it can cause fetal distress, it does not explain the maternal symptoms like the sudden, severe lower abdominal pain, hypotension, cool skin, and pallor. Prolonged bradycardia on the fetal heart rate tracing is more suggestive of uterine rupture.

A. A client who is at 34 weeks of gestation and is experiencing epigastric pain and headache. B. A client who is at 12 weeks of gestation and is experiencing nausea and vomiting. C. A client who is at 38 weeks of gestation and is experiencing painful urination. D. A client who is at 39 weeks of gestation and is experiencing cramping and spotting.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should assess this client first as they are at 34 weeks of gestation and experiencing epigastric pain and headache. These symptoms could be indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia requires immediate assessment and intervention to prevent further complications.

Choice B rationale:

Nausea and vomiting are common symptoms during the first trimester of pregnancy, and at 12 weeks of gestation, it is less likely to be a critical issue compared to potential preeclampsia.

Choice C rationale:

Painful urination may indicate a urinary tract infection, which can be important to assess and treat, but it is not as urgent as potential signs of preeclampsia in a client at 34 weeks of gestation.

Choice D rationale:

Cramping and spotting can be normal signs of impending labor, especially at 39 weeks of gestation. While it's important to assess this client, it is not the priority over potential preeclampsia in a client at 34 weeks of gestation with symptoms of epigastric pain and headache.

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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?

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Correct Answer is B

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