A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client's ability to eliminate urine from the bladder is restored?
Fundus 2 fingerbreadths above the umbilicus
Uterine atony
Fundus firm and to the right of the abdominal midline
Two voids of 150 mL each over the past 2 hr
The Correct Answer is D
A. Fundus 2 fingerbreadths above the umbilicus: This finding relates to uterine involution rather than urinary elimination. While important for postpartum assessment, it does not indicate restored bladder function.
B. Uterine atony: Uterine atony is a complication that increases the risk of postpartum hemorrhage. It does not provide information about the client’s ability to void and requires separate monitoring and intervention.
C. Fundus firm and to the right of the abdominal midline: A firm but displaced fundus may indicate a full bladder, which can interfere with urination. This finding suggests bladder distention rather than restored urinary elimination.
D. Two voids of 150 mL each over the past 2 hr: Adequate urine output in regular intervals indicates that the bladder is emptying effectively. Measuring volume and frequency confirms the client’s ability to eliminate urine has been restored postpartum.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Bulging fontanel: A bulging fontanel typically indicates increased intracranial pressure, not dehydration. In dehydration, the fontanel is more likely to appear sunken in infants, making this an incorrect finding to monitor for fluid loss.
B. Weight loss: Weight loss is a key indicator of fluid loss in infants. Monitoring daily weight provides an objective measure of dehydration severity and effectiveness of rehydration interventions, making it a critical finding for the nurse to track.
C. Distended jugular vein: Jugular vein distention is associated with fluid overload or cardiac issues, not dehydration. This finding would be unlikely in a 3-month-old infant with gastroenteritis.
D. Bradycardia: Dehydration in infants typically presents with tachycardia as the body compensates for decreased fluid volume. Bradycardia is not a common sign of dehydration and may indicate another underlying condition.
Correct Answer is A
Explanation
A. Client reports popping sensation at the wound: A popping or tearing sensation at the surgical site can indicate wound dehiscence or evisceration, which is a surgical emergency. Immediate reporting to the provider is essential for prompt intervention to prevent further complications.
B. Client is tender to touch at the surgical site: Mild tenderness is expected 24 hours postoperatively due to inflammation and tissue trauma. While it should be monitored, it is not an urgent finding requiring immediate provider notification.
C. Crusting on the client's incision line: Light crusting is a normal part of the healing process and does not typically indicate a complication. Routine wound care and monitoring are sufficient.
D. Serosanguineous drainage on the client's dressing: Serosanguineous drainage is expected within the first 24–48 hours after surgery. It is a normal finding and usually does not require urgent reporting unless it increases significantly or changes character.
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