A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?”. Which action should the practical nurse (PN) implement?
Catheterize the client for residual urine volume.
Evaluate for normal involution, then massage the fundus.
Measure the next voiding, then palpate the client's bladder.
Obtain a specimen for urine culture and sensitivity.
The Correct Answer is C
Correct Answer: C. Measure the next voiding, then palpate the client's bladder.
Choice A rationale:
Catheterizing the client for residual urine volume is not necessary at this point because the woman has recently given birth, and frequent urination is common during the postpartum period. Additionally, catheterization poses risks of infection, so it should be reserved for situations where it is clinically indicated.
Choice B rationale:
Evaluating for normal involution and massaging the fundus is not relevant in this context. Fundal massage is performed after childbirth to ensure the uterus contracts and prevents excessive bleeding. The woman's concern is about frequent urination, which does not require fundal massage.
Choice C rationale:
Measuring the next voiding and palpating the client's bladder is the most appropriate action. The woman's increased frequency of urination could be due to postpartum diuresis, a normal physiological process where the body eliminates excess fluid accumulated during pregnancy. By measuring the next voiding and palpating the bladder, the nurse can assess for bladder distension or retention, which could be signs of a problem.
Choice D rationale:
Obtaining a specimen for urine culture and sensitivity is not indicated in this situation. There is no evidence to suggest that the woman has a urinary tract infection or other urinary issues that would warrant a urine culture at this time.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Report the findings to the charge nurse. Choice A rationale:
Encouraging the client to drink fluids is not the priority in this situation. While hydration is important, the client's symptoms of muscle soreness, fatigue, and warm skin might indicate a potential adverse reaction to the statin medication, which requires immediate attention.
Choice B rationale:
Monitoring the client's serum lipid levels is not the priority at this moment. The client's current symptoms suggest a possible adverse reaction to the statin medication, and waiting for lipid level results may delay necessary interventions.
Choice C rationale:
Reporting the findings to the charge nurse is the priority action. The client's symptoms could be signs of rhabdomyolysis, a severe and potentially life-threatening condition where muscle breakdown releases toxic substances into the bloodstream. The charge nurse needs to be informed promptly so that appropriate interventions can be initiated.
Choice D rationale:
Administering a PRN dose of acetaminophen is not the priority in this situation. Acetaminophen may help with pain relief, but it will not address the potential underlying issue of muscle soreness and fatigue related to the statin medication.
Correct Answer is D
Explanation
The correct answer is choice D: Provide fluid and electrolyte replacement. Choice A rationale:
Isolating all infectious diarrhea victims is not the highest priority in this situation. While it is essential to prevent the spread of cholera, immediate medical intervention to treat those affected takes precedence.
Choice B rationale:
Administering prophylactic antibiotics as prescribed is not the highest priority because it focuses on prevention rather than treatment. In the case of a cholera outbreak, it is more critical to address the immediate needs of those already diagnosed.
Choice C rationale:
Administering cholera vaccines may be part of a preventive strategy, but it is not the highest priority during an active cholera outbreak. Vaccination takes time to develop immunity, and the focus should be on treating those already affected.
Choice D rationale:
Providing fluid and electrolyte replacement is the highest priority in managing cholera. Cholera is characterized by severe diarrhea and dehydration, which can lead to life-threatening complications. Promptly restoring fluids and electrolytes helps prevent shock and organ failure.
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