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 B
Explanation
A. A cephalhematoma is a collection of blood under the periosteum that does not cross the suture lines and can take weeks to resolve.
B. Caput succedaneum occurs due to compression of blood vessels during delivery, resulting in edema and bruising of the scalp. It crosses the suture lines and usually resolves within a few days and does not cause any complications.
C. Erythema toxicum is a rash that is unrelated to head swelling.
D. Mongolian spots are blue-gray patches on the skin, not associated with head swelling.
Correct Answer is ["120"]
Explanation
To calculate the infusion rate in gtt/min, the nurse needs to use the formula: gtt/min = (mL/hr x drop factor) / 60
Plugging in the given values, we get:
gtt/min = (120 mL/hr x 60 gtt/mL) / 60
gtt/min = 7200 gtt/hr / 60 gtt/min = 120 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 120 gtt/min.
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