A nurse is caring for a group of clients who are postpartum.
Which of the following clients is at an increased risk for a fall?
A client who has an indwelling urinary catheter.
A client who has a second-degree perineal laceration.
A client who is saturating a perineal pad every 5 to 6 hr.
A client who is experiencing breast engorgement.
The Correct Answer is A
Choice A rationale
An indwelling urinary catheter can increase the risk of falls because it may cause discomfort and restricted mobility, leading the client to move awkwardly or lose balance.
Choice B rationale
While a second-degree perineal laceration might cause pain and limited mobility, it doesn't usually contribute as significantly to fall risk as an indwelling catheter.
Choice C rationale
Saturating a perineal pad every 5 to 6 hours may indicate heavy postpartum bleeding, but it isn't directly related to fall risk. The concern here would be more about monitoring for hemorrhage rather than falls.
Choice D rationale
Breast engorgement causes discomfort and pain but doesn't directly affect a client's mobility or balance, making it less likely to increase fall risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Uterine contractions occur more frequently than every 15 minutes during the active phase of labor, typically every 2-3 minutes.
Choice B rationale
A fetal heart rate baseline of 166/min is considered tachycardia and may not be normal during labor.
Choice C rationale
Late decelerations are concerning and not expected as they may indicate fetal distress.
Choice D rationale
Contractions lasting about 75 seconds are expected during the active phase of labor.
Correct Answer is C
Explanation
Choice A rationale
Patterned breathing techniques can help in managing pain by focusing on controlled breathing, reducing anxiety, and providing a distraction from the pain, but are not specifically targeting back labor pains.
Choice B rationale
Effleurage involves light circular strokes on the abdomen and can help in managing general labor pain, but may not be as effective specifically for back labor pains.
Choice C rationale
Sacral counterpressure involves applying steady pressure to the sacral area, which can help relieve pain caused by back labor by counteracting the discomfort experienced in this area.
Choice D rationale
Guided imagery involves using mental visualization to distract from pain and promote relaxation, but may not be as effective in relieving the specific pain associated with back labor.
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