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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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 B
Explanation
A. This is not appropriate for the taking-in stage, as the woman may not be ready to absorb new information or focus on self-care. She may need more verbal instruction and demonstration from the nurse.
B. The taking-in stage is a period of passive, dependent behavior in which the woman reviews her childbirth experience and adjusts to the new role of motherhood. She may need to talk about her labor and delivery repeatedly and seek reassurance from others. The nurse should listen attentively and validate her feelings.
C. This is more suitable for the taking-hold stage, which occurs after the taking-in stage. In this stage, the woman becomes more active and independent, and shows interest in learning how to care for herself and her baby.
D. This is also more appropriate for the taking-hold stage, when the woman develops confidence and competence in her maternal role. In the taking-in stage, she may be more focused on her own needs and rely on others to care for the baby.
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