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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is the finding that the PN should report to the charge nurse because it indicates a possible complication of Guillain-Barre syndrome, which is autonomic dysfunction. This can affect the cardiac, respiratory, and gastrointestinal systems and cause life-threatening problems such as arrhythmias, hypotension, or respiratory failure. The PN should monitor the client's vital signs closely and report any abnormal changes.
B. Profuse diaphoresis is not a priority finding and may be related to other factors such as fever, anxiety, or medication side effects.
C. Lower leg weakness is an expected finding in Guillain-Barre syndrome and does not need to be reported unless it progresses rapidly or affects the respiratory muscles.
D. Full facial flushing is not a priority finding and may be related to other factors such as vasodilation, inflammation, or medication side effects.
Correct Answer is A
Explanation
Suction the trachea.
Choice A rationale:
The practical nurse (PN) should ensure the ready availability of equipment to perform tracheal suctioning for a client who requires seizure precautions. Seizures can sometimes cause excessive salivation or even vomiting, which may lead to the obstruction of the airway. Suctioning the trachea helps in quickly clearing any secretions or vomitus from the airway, preventing potential respiratory compromise and ensuring the client's airway remains patent.
Choice B rationale:
Inserting a nasogastric tube is not directly related to seizure precautions. Nasogastric tubes are used for various purposes, such as decompression of the stomach, feeding, or administering medications. While it might be necessary in specific situations, it is not a priority when caring for a client on seizure precautions.
Choice C rationale:
Inserting a urinary catheter is also not directly related to seizure precautions. It is typically done for clients who have difficulty urinating on their own or for precise monitoring of urine output. Seizure precautions focus on the client's airway and safety during a seizure episode.
Choice D rationale:
Applying soft restraints is generally not recommended for clients on seizure precautions. Restraints should only be used as a last resort for clients who pose a risk to themselves or others during a seizure. The primary goal is to provide a safe environment and prevent injuries without restraining the client unless absolutely necessary.
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