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 ["A","B","D","E"]
Explanation
A. Blotting the perineal area dry helps prevent moisture retention, reducing the risk of infection.
B. Performing hand hygiene before and after voiding helps prevent the introduction of bacteria into the perineal area.
C. Applying ice packs may help reduce swelling but is not a routine measure for preventing infection.
D. Cleaning the perineal area from front to back helps prevent the introduction of fecal bacteria into the urethra and vagina.
E. Washing the perineal area using a squeeze bottle of warm water after each voiding helps maintain cleanliness and prevent infection.
Correct Answer is C
Explanation
A. A hot pack to the perineum can be offered after 24 hours, but not before, as heat can increase bleeding.
B. A warm sitz bath can be offered after 24 hours, but not before, as heat can increase bleeding and infection risk.
C. The nurse should also apply an ice pack to the perineum for 20 minutes every 4 hours to reduce swelling and inflammation.
D. Providing a squeeze bottle of antiseptic solution is more related to perineal hygiene rather than pain relief.
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