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 D
Explanation
This is the factor that the PN should consider the most likely to increase the client's risk for falls because it can cause orthostatic hypotension, dizziness, or fainting, especially when the client changes position or gets up from bed or a chair. The PN should monitor the client's blood pressure and pulse before and after administering the medication and assist the client with ambulation and transfers.
Correct Answer is A,B,D,C
Explanation
= The correct sequence is: A. Perform standard hand washing, B. Put on disposable gown, D. Don a pair of procedure gloves, C. Remove gloves and gown in the room.
Choice A rationale:
Performing standard hand washing before donning personal protective equipment (PPE) is essential to ensure that the UAP's hands are clean before putting on gloves and gown.
Choice B rationale:
Putting on a disposable gown is the next step after hand washing to protect the UAP's clothing from potential contamination.
Choice D rationale:
Donning a pair of procedure gloves is the next step after putting on the gown to protect the UAP's hands from contact with potentially infectious material.
Choice C rationale:
Removing gloves and gown in the client's room is the last step in the sequence. This step ensures that any potential contaminants stay within the isolation room and do not spread to other areas of the facility.
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