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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Drying the newborn's skin thoroughly helps reduce evaporative heat loss by removing wetness and promoting warmth.
B. Preventing air drafts is important to reduce convective heat loss.
C. Placing the newborn on a warm surface helps prevent conductive heat loss.
D. Maintaining ambient room temperature is important but does not directly address evaporative heat loss.
Correct Answer is D
Explanation
A. Wearing a loose-fitting bra may provide comfort but does not address the underlying issue of engorgement.
B. Expressing small amounts of milk may stimulate further milk production and is not recommended in cases of bottle-feeding.
C. Running warm water on the breasts may increase blood flow and exacerbate swelling.
D. Cold compresses or ice are more appropriate for relieving discomfort and reducing swelling.
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