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
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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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
A. Changing the perineal pad of a client who has just been transferred from the labor ward is a task that should not be delegated to an assistive personnel (AP) since it is beyond their scope.
B. Monitoring vital signs during the admission of a client with gestational hypertension requires nursing judgment and assessment skills.
C. Providing a sitz bath to a client with a fourth-degree laceration and is 2 days post- partum can be delegated to an AP. This task does not require the nurse's clinical judgment or assessment skills, and it can be safely performed by the AP following the nurse's instructions.
D. Observing an area of redness on the breast requires nursing assessment and intervention.
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