A nurse is caring for a postpartum client who recently had an indwelling urinary catheter removed. Which of the following findings indicates that the client is able to void effectively?
The client urinates 30 mL/hr.
The client does not feel the urge to urinate.
The uterine fundus is 2 cm above the umbilicus.
The bladder is distended upon palpation.
The Correct Answer is A
Choice A rationale:
Urinating 30 mL/hr is correct. This is within the normal urinary output range of 30 to 60 mL/hr, indicating effective voiding.
Choice B rationale:
Not feeling the urge to urinate is incorrect. This could indicate urinary retention, not effective voiding.
Choice C rationale:
A uterine fundus 2 cm above the umbilicus is incorrect. This is unrelated to the client’s ability to void effectively.
Choice D rationale:
A distended bladder upon palpation is incorrect. This could suggest urinary retention, not effective voiding.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Myelomeningocele is the most severe type of spina bifida, a birth defect in which the spinal cord and its protective covering (meninges) protrude outside the body through an opening in the spine. This can cause nerve damage, muscle weakness, bladder and bowel dysfunction, and/or paralysis. Myelomeningocele requires surgical treatment after birth to repair the opening in the spine and prevent infections and further complications. According to the Mayo Clinic, the following actions should be included in the plan of care for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid:
Cover the sac with a sterile, moist dressing to prevent it from drying out and becoming infected.
Place the baby in a prone position (on the stomach) or on the side to avoid putting pressure on the sac.
Monitor the vital signs, especially the temperature, as the baby may have difficulty regulating body temperature.
Administer antibiotics as prescribed to prevent meningitis and other infections.
Prepare for surgical closure of the sac within the first 24 to 48 hours after birth.
Therefore, the correct answer to your question is d. Administer broad-spectrum antibiotics. The other options are not appropriate for the immediate postnatal care of a newborn with myelomeningocele. Preparing for surgical closure after 72 hours is too late, as the risk of infection and complications increases with time. Monitoring the rectal temperature every 4 hours is not enough, as the baby may need more frequent checks and interventions to maintain a normal body temperature. Cleansing the site with povidone-iodine is not recommended, as it may irritate the delicate tissues and cause more harm than good
Correct Answer is A
Explanation
Choice A rationale:
Yellowed sclera in a newborn could indicate jaundice, which should be reported to the provider.
Choice B rationale:
Stooling after each breastfeeding is normal for a newborn.
Choice C rationale:
Intermittent crossing of eyes is common in newborns and usually resolves by 3 months of age.
Choice D rationale:
Voiding eight to ten times per day is normal for a newborn.
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