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 D

Explanation

A. A respiratory rate of 110/min is too high for a newborn and may indicate respiratory distress.
B. A respiratory rate of 100/min is too high for a newborn and may indicate respiratory distress.
C. A respiratory rate of 22/min is too low for a newborn.
D. A normal respiratory rate for a newborn is between 40 and 60 breaths per minute.

A. Infants fed on formula should be started on solid food sooner than breastfed infants B. Infants should be given only human milk for the first 6 months of life. C. After 6 months, mothers should shift from breast milk to cow's milk D. If infants are weaned from breast milk before 12 months, then they should receive cow's milk, not formula.

Correct Answer is B

Explanation

A. The introduction of solid food is recommended at similar times for both breastfed and formula-fed infants.
B. The AAP recommends exclusive human milk feeding for the first 6 months of life.
C. After 6 months, complementary foods are introduced, not a shift to cow's milk.
D. If weaned before 12 months, formula is a suitable alternative to breast milk.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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