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 A
Explanation
Rationale:
A. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field: Dropping sterile items from a height of about 6 to 12 inches prevents contamination by keeping hands outside the sterile field and ensuring the item lands safely without touching nonsterile surfaces.
B. Hold the sterile package in his dominant hand and open the top flap of the package toward his body: The top flap should be opened away from the nurse’s body to maintain sterility and prevent the arm from crossing over the sterile field, which would risk contamination.
C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field: The outer 2.5 cm (1 inch) of the sterile field is considered contaminated. Placing items only 0.5 inches inside this border would place them within the contaminated zone, risking sterile field compromise.
D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container: While the bottle should not touch the sterile field, it must be close enough to pour without splashing, and the sterile container must be inside the sterile field.
Correct Answer is D
Explanation
Rationale:
A. "Perform aerobic activities three times per week.": While exercise can be beneficial, excessive aerobic activity may worsen fatigue in clients with MS. Low-impact and well-paced exercise is more appropriate.
B. "Soak in a hot bath.": Heat can exacerbate symptoms in clients with MS by increasing nerve conduction issues, potentially leading to worsening fatigue or vision changes.
C. "Have your partner complete activities of daily living for you.": Encouraging dependence can contribute to decreased function and self-esteem. Clients should be supported to remain as independent as possible within their limits.
D. "Schedule rest periods during the day.": Fatigue is a common symptom of MS. Rest periods help conserve energy and prevent exacerbation of symptoms, promoting better overall functioning.
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