A nurse is caring for a client who is 1 hr postpartum and unable to urinate.
Which of the following actions should the nurse take?
Place the client's hands in warm water.
Perform a fundal massage.
Administer a benzodiazepine.
Place an ice pack on the client's perineum.
The Correct Answer is A
Choice A rationale:
Placing the client's hands in warm water is a method to stimulate urination and is appropriate for clients experiencing difficulty voiding.
Choice B rationale:
Performing a fundal massage is incorrect choice in this scenario.
Choice C rationale:
Administering a benzodiazepine is not appropriate for this situation. Benzodiazepines are a class of medications primarily used for anxiety, insomnia, and seizures. There is no indication for the use of benzodiazepines in this case, as the client's inability to urinate is likely related to a physiological issue postpartum, not anxiety or seizures.
Choice D rationale:
Placing an ice pack on the client's perineum is not the correct intervention for this situation. Ice packs on the perineum are typically used to reduce swelling and relieve pain after childbirth. However, the client's inability to urinate suggests a potential issue within the urinary system, and a fundal massage to promote uterine contractions would be more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Requesting a provider to evaluate the client in person every 36 hours might be necessary in certain situations but is not directly related to the management of a client in seclusion and restraints. It does not ensure the immediate safety and well-being of the client in this scenario.
Choice B rationale:
Documenting the client's behavior every 15 minutes is essential when a client is in seclusion and restraints. Regular and detailed documentation is crucial to monitor the client's response to the intervention, ensuring their safety, and providing necessary information for the healthcare team.
Choice C rationale:
Ensuring that the prescription for restraints be renewed every 6 hours is important to prevent unnecessary or prolonged use of restraints, but it doesn't address the immediate need for monitoring the client in seclusion and restraints.
Choice D rationale:
Monitoring the client every 30 minutes while restrained might not provide timely information, especially if the client's condition deteriorates rapidly. More frequent monitoring, such as every 15 minutes, allows for closer observation and quicker response to any changes in the client's status.
Correct Answer is C
Explanation
Answer is: c. Protect the IV bag from exposure to light.
Explanation: Nitroprusside degrades when exposed to light, so the nurse should protect the IV bag from light exposure to maintain the medication's potency and effectiveness in treating the client's severe hypertension.
Choice a. is wrong because calcium gluconate is used as an antidote for magnesium sulfate toxicity. Although it may be kept on hand in some facilities, it is not directly related to the administration of nitroprusside.
Choice b. is wrong because attaching an inline filter is not necessary when administering nitroprusside. It is more relevant for medications that require filtration, such as certain chemotherapeutic agents.
Choice d. is wrong because monitoring blood pressure every 2 hours is not frequent enough for a client receiving nitroprusside. The nurse should monitor the client's blood pressure more frequently, such as every 5 to 15 minutes, depending on facility policies and the client's condition.
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