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. Fibrocystic breast condition: This benign breast disorder does not interfere with the use of oral contraceptives. In fact, hormonal birth control may sometimes reduce breast pain and nodularity associated with this condition.
B. Hypertension: High blood pressure is a known contraindication for oral contraceptive use, especially if it is uncontrolled. Estrogen-containing contraceptives can further elevate blood pressure and increase the risk of cardiovascular events such as stroke or myocardial infarction.
C. Fibromyalgia: Fibromyalgia does not interact with oral contraceptives and is not a contraindication. While hormonal changes may influence pain perception, there is no direct risk in using contraceptives for someone with this condition.
D. Asthma: Asthma is not a contraindication to using oral contraceptives. There is no evidence that hormonal contraceptives worsen asthma symptoms or interfere with its management.
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}
Explanation
Rationale:
- Platelet count: A low platelet count (<100,000/mm³) is a hallmark of HELLP syndrome but can also appear in severe preeclampsia. Therefore, thrombocytopenia supports both diagnoses.
- Alanine aminotransferase (ALT): Elevated ALT indicates hepatic involvement due to hepatocellular injury, which is a defining feature of HELLP syndrome but not required for preeclampsia diagnosis.
- Blood pressure: Severe hypertension (≥160/110 mm Hg), as seen in this client, is diagnostic of severe preeclampsia. It may also be present in HELLP syndrome due to overlapping pathophysiology.
- Hemoglobin: Low hemoglobin can reflect hemolysis, which is part of the HELLP acronym (Hemolysis, Elevated Liver enzymes, Low Platelets). Preeclampsia does not typically present with anemia unless HELLP develops.
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