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. Insert the catheter into the foot: While the scalp and foot veins may be used in infants, foot veins are less preferred in mobile infants due to the risk of dislodgement. Site selection should prioritize accessible and secure veins, often in the hand or scalp.
B. Obtain a 24-gauge catheter: A 24-gauge catheter is the appropriate size for infants due to their small and delicate veins. It minimizes trauma during insertion and allows for adequate flow while reducing the risk of vein damage.
C. Use gauze to cover the IV insertion site: Transparent dressings, not gauze, are preferred for covering IV sites in infants. They allow for continuous visualization of the site to detect signs of infiltration or infection promptly.
D. Monitor the IV site every 8 hours: IV sites in infants should be monitored much more frequently due to their higher risk of infiltration, dislodgement, or phlebitis. Hourly monitoring is standard practice, especially in high-acuity or pediatric settings.
Correct Answer is D
Explanation
Rationale:
A. "I will set a timer for 10 minutes for each timeout session.": Timeout duration should be age-appropriate, generally one minute per year of the child's age. A 10-minute timeout for a toddler would be too long and ineffective for promoting behavioral correction.
B. "My child will learn rules through physical punishment.": Physical punishment is not recommended for children as it may lead to increased aggression, fear, and long-term emotional harm. Positive discipline strategies like timeouts and redirection are more appropriate.
C. "I will remind my child of their misbehavior to reinforce discipline.": Repeated reminders can reinforce negative behavior by drawing excessive attention to it. Discipline should focus on clear, consistent consequences rather than prolonged discussion of misbehavior.
D. "A timeout session should begin once my child is quiet.": Timeout should start after the child calms down to encourage self-regulation. Starting it during a tantrum may reinforce the behavior, while waiting promotes emotional control and helps the child learn to calm themselves.
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