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 C

Explanation

A. Acrocyanosis is a normal finding in newborns and does not require immediate intervention.
B. Not passing meconium within the first 24 hours is not uncommon and may be normal.
C. Persistent tachycardia in a newborn, especially with a heart rate of 180 bpm, requires immediate intervention as it may indicate a cardiac or other medical issue.
D. Not voiding within the first 24 hours may be normal, but it should be monitored.

A. Allow the newborn to continue crying. B. Keep the newborn in the center of a large crib. C. Carry the newborn evert time he/she cries. D. Swaddle the newborn in a receiving blanket.

Correct Answer is D

Explanation

A. Allowing the newborn to continue crying without attempting to soothe the baby is not an appropriate strategy for responsive parenting.
B. Keeping the newborn in the center of a large crib without attending to the baby's needs is not responsive caregiving.
C. Carrying the newborn every time he/she cries may not be practical or necessary, and it's important to encourage safe sleep practices.
D. Swaddling the newborn in a receiving blanket can provide comfort and a sense of security, promoting sleep and reducing crying.

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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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Explanation

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Correct Answer is D

Explanation

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