Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible.
If all else fails, the last thing the nurse could try is:
Pouring water from a squeeze bottle over the woman’s perineum.
Placing oil of peppermint in a bedpan under the woman.
Asking the physician to prescribe analgesics.
Inserting a sterile catheter.
The Correct Answer is B
This is because oil peppermint can stimulate the micturition reflex and help the woman to void.
Some possible explanations for the other choices are:
Choice A is wrong because pouring water over the perineum may not be enough to trigger the micturition reflex and may cause discomfort or infection.
Choice C is wrong because analgesics may not address the underlying cause of urinary retention and may have side effects such as drowsiness or nausea.
Choice D is wrong because inserting a sterile catheter is an invasive procedure that carries risks such as trauma, infection, or bladder spasms. It should be used only as a last resort after other methods have failed.
Normal ranges for postpartum bladder function are:
- Urine output: 3000 to 5000 mL/day for the first 2 to 3 days after delivery.
- Urine specific gravity: 1.005 to 1.030.
- Urine pH: 4.6 to 8.0.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Verbalizing the importance of monitoring for medication side effects.
Graves’ disease is an autoimmune disorder that causes hyperthyroidism, which means the thyroid gland produces too much thyroid hormone. This can lead to symptoms such as weight loss, increased appetite, nervousness, irritability, insomnia, heat intolerance, and palpitations. The medication methimazole is used to treat Graves’ disease by blocking the synthesis of thyroid hormone. However, methimazole can also cause serious side effects such as liver damage, agranulocytosis (low white blood cell count), and allergic reactions.
Therefore, the priority nursing goal for a 14 year old diagnosed with Graves’ disease is to verbalize the importance of monitoring for medication side effects and reporting them to the health care provider.
Choice A is wrong because relieving constipation is not a priority goal for Graves’ disease. Constipation is more likely to occur in hypothyroidism, which is the opposite of hyperthyroidism.
Choice B is wrong because allowing the adolescent to make decisions about whether or not to take medication is not a priority goal for Graves’ disease. While it is important to respect the adolescent’s autonomy and involve them in their care plan, they also need to understand the risks and benefits of taking medication and the consequences of not taking it.
Choice D is wrong because developing alternative educational goals is not a priority goal for Graves’ disease. Graves’ disease can affect the academic performance of adolescents due to cognitive and emotional changes caused by hyperthyroidism.
However, this does not mean that they need to change their educational goals. They may need extra support and accommodations from their teachers and parents to cope with their condition and achieve their potential.
Correct Answer is D
Explanation
This test measures the amount of chloride in the sweat, which is abnormally high in people with cystic fibrosis (CF). CF is an inherited disorder that affects the cells that produce mucus, sweat, and digestive juices.
Choice A is wrong because bronchoscopy is a procedure that allows the doctor to examine the airways and lungs, but it is not essential for diagnosing CF.
Choice B is wrong because serum calcium is a blood test that measures the level of calcium in the blood, which is not related to CF.
Choice C is wrong because urine creatinine is a test that measures the amount of creatinine in the urine, which reflects the kidney function, but it is not relevant to CF.
Normal ranges for sweat chloride test are:
- Less than 40 millimoles per liter (mmol/L) for children and adults
- Less than 30 mmol/L for infants younger than 6 months
A sweat chloride level of more than 60 mmol/L is considered positive for CF.
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