A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Fundus palpable to right of midline

Less than 2.5 cm of rubra lochia on perineal pad

Client report of increased thirst

Client report of frequent uterine contractions

Answer and Explanation

The Correct Answer is A

A.   A fundus palpable to the right of midline may indicate a distended bladder pushing the uterus to the side, and it requires intervention to promote bladder emptying.
B.   Less than 2.5 cm of rubra lochia on a perineal pad is a normal finding in the early postpartum period.
C. Increased thirst is not directly indicative of bladder distention.
D.   Frequent uterine contractions are expected in the postpartum period and do not necessarily indicate bladder distention.

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Correct Answer is C

Explanation

A. Placing the baby on the stomach is not recommended due to the risk of sudden infant death syndrome (SIDS).
B. Placing the crib next to the heater may cause overheating, which is a risk factor for SIDS.
C. Removing extra blankets from the baby's crib is important to reduce the risk of SIDS.
D. Padding the mattress in the baby's crib is not recommended as it can pose a suffocation risk.

A. Ensure the infant breastfeeds in the first hour. B. Perform a glucose test for the infant before feeding. C. Administer intravenous dextrose infusion within 2 hours. D. Ensure the infant is fed every hour for the first 24 hours.

Correct Answer is A

Explanation

A. This intervention is correct because it provides the infant with a source of glucose and helps prevent hypoglycemia.
B. A glucose test alone may not provide timely intervention if hypoglycemia is detected.
C. Administering intravenous dextrose infusion is a rapid and effective way to address hypoglycemia, but early breastfeeding should be the priority action.
D. While frequent feeding is beneficial, intravenous dextrose may be necessary for a more immediate impact.

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A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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