A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?
Client report of frequent uterine contractions.
Fundus palpable to right of midline.
Less than 2.5 cm of rubra lochia on perineal pad.
Client report of increased thirst.
The Correct Answer is B
Choice A reason:
If the client reports frequent uterine contractions , it is not indicative of a distended bladder. Postpartum uterine contractions are normal and necessary to help the uterus return to its pre-pregnancy size.
Choice B reason:
The fundus (the top portion of the uterus being palpable to the right of the midline suggests a distended bladder. A full bladder can displace the uterus, causing the fundus to deviate from the midline.
Choice C reason:
Having less than 2.5 cm of rubra lochia on a perineal pad is related to the amount of vaginal discharge after birth and does not provide information about bladder distention.
Choice D reason:
The client's report of increased thirst may indicate dehydration or the body's response to fluid loss during childbirth but is not directly related to bladder distention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Lochial color changes from rubra to alba in the early postpartum period is a normal event. Lochia is the vaginal discharge that occurs after childbirth, and it progresses from bright red (rubra) to pink or brownish (serosa) to whitish-yellow (alba) as the days pass.
Choice B reason:
Extreme hunger and thirst in the early postpartum period may indicate abnormal blood sugar levels and can be a sign of gestational diabetes or other metabolic disorders. It requires further evaluation and monitoring by healthcare providers.
Choice C reason:
Diuresis (increased urination) and diaphoresis (increased sweating) are normal events in the early postpartum period. After childbirth, the body eliminates excess fluid that was retained during pregnancy, leading to increased urination and sweating.
Choice D reason:
Flatulence (passing gas) and constipation can be normal events in the early postpartum period due to the body recovering from the effects of labor, changes in diet, and the use of pain medications during childbirth.
Correct Answer is A
Explanation
Choice A reason:
Babinski's Reflex is the normal response in infants when the sole of the foot is stroked from the heel to the ball of the foot. The big toe moves upward or toward the top surface of the foot, and the other toes fan out. This reflex is normal in children up to 2 years old, and it disappears as the nervous system matures. It may indicate damage to the central nervous system in older children and adults.
Choice B reason:
Stepping Reflex is the normal response in infants when they are held upright with their feet touching a flat surface. They will lift one foot and then the other, as if they are walking. This reflex is present at birth and lasts for about 2 months. It helps prepare the infant for voluntary walking.
Choice C reason:
Moro Reflex is the normal response in infants when they are startled by a loud noise or a sudden movement. They will extend their arms and legs, open their hands, and then curl up and bring their arms together as if they are hugging themselves. This reflex is present at birth and lasts for about 4 to 6 months. It is thought to be a protective response that helps the infant cling to their caregiver.
Choice D reason:
Plantar Grasp Reflex is the normal response in infants when pressure is applied to the sole of the foot near the toes. The toes will curl down and grasp the stimulus. This reflex is present at birth and lasts for about 9 to 12 months. It is similar to the palmar grasp reflex in the hands, and it helps develop the muscles and nerves in the feet. Some additional sentences are:. If you are interested in learning more about infant development, you can check out some of these links:. • [A guide to newborn reflexes]. • [A video demonstration of newborn reflexes].
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.