A nurse is caring for a client who has not voided since giving birth vaginally 10 hours ago. Which of the following actions should the nurse take?
Palpate the client's bladder in 1 hour.
Place the client's hands in a bowl of cold water.
Have the client listen to running water while on the toilet.
Perform effleurage over the client's lower abdomen.
The Correct Answer is C
Rationale:
A. Palpate the client's bladder in 1 hour: Waiting another hour to assess the bladder delays intervention. At 10 hours postpartum with no void, immediate action is needed to stimulate voiding or assess for urinary retention.
B. Place the client's hands in a bowl of cold water: This technique is more commonly used in children and is less effective in stimulating voiding in postpartum adults. It is not a first-line strategy in this context.
C. Have the client listen to running water while on the toilet: This is a noninvasive and effective method to stimulate the urge to void by triggering the micturition reflex. It can help relax pelvic muscles and encourage urination postpartum.
D. Perform effleurage over the client's lower abdomen: Effleurage is a light massage technique used primarily for labor pain management. It is not a recognized or effective method to promote urination in postpartum care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Limit teaching sessions about the procedure to 20 min: Preschoolers have short attention spans, but 20 minutes is still too long for teaching at this developmental stage. Teaching should be concise and focused, ideally lasting only a few minutes just before the procedure.
B. Explain in simple terms how the procedure will affect the child: Preschoolers benefit from clear, age-appropriate explanations that help them understand what to expect. Using simple language and concrete terms reduces fear and builds trust with the nurse.
C. Ask the parents to wait outside the room during the procedure: Parents often provide comfort and reassurance during stressful experiences. Unless they are interfering or the child requests otherwise, their presence can help reduce the child’s anxiety.
D. Instruct the child in deep-breathing methods prior to the procedure: While relaxation techniques are helpful for older children, preschoolers may have difficulty understanding and following deep-breathing instructions. Simple distraction methods are often more effective.
Correct Answer is D
Explanation
Rationale:
A. Bradycardia: Ectopic pregnancy is more likely to cause tachycardia due to internal bleeding and hypovolemia from tubal rupture. Bradycardia is not a typical finding and would suggest a different or more advanced issue.
B. Hypertension: Hypotension, not hypertension, may occur in cases of significant bleeding from a ruptured ectopic pregnancy. Elevated blood pressure is not a hallmark sign of this condition.
C. Hydramnios: Hydramnios refers to excessive amniotic fluid and is associated with fetal anomalies or maternal diabetes. It is unrelated to ectopic pregnancy, where implantation occurs outside the uterine cavity.
D. Abdominal pain: Sharp or stabbing abdominal or pelvic pain is a classic symptom of ectopic pregnancy. It may be accompanied by vaginal bleeding and referred shoulder pain if internal bleeding irritates the diaphragm.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.