The nurse is assessing the urinary output of a patient 4 hours after a caesarean birth. The patient weighs 68 kg and the indwelling catheter bag measures 125 mL of urine. Which action will the nurse include in the plan of care?

Discontinue the indwelling catheter.

Increase intravenous fluid rate.

Check the catheter for patency.

Document the finding.

Answer and Explanation

The Correct Answer is C

Choice A reason: Discontinuing the indwelling catheter is not appropriate without first assessing the cause of the low urine output.

Choice B reason: Increasing the intravenous fluid rate might be considered if the patient is dehydrated, but first, the nurse should ensure that the low urine output is not due to a mechanical issue with the catheter.

Choice C reason: Checking the catheter for patency is the most immediate and appropriate action. There could be a blockage or kink in the catheter, which might explain the low urine output.

Choice D reason: Documenting the finding is important, but it should be done after addressing the immediate concern of low urine output and confirming that the catheter is functioning properly.

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Correct Answer is A

Explanation

Choice A reason: Lack of prenatal care is a significant risk factor for neural tube defects, including myelomeningocele, because it often means the mother did not receive important prenatal vitamins like folic acid, which are crucial for proper neural tube development. Prenatal care provides essential screenings and supplements to support a healthy pregnancy and fatal development. Without it, the risk of congenital anomalies, such as myelomeningocele, increases significantly. Additionally, prenatal care helps in identifying and managing other risk factors and conditions that may affect both maternal and fatal health.

Choice B reason: While active Labor with wounds requires medical attention and may pose risks to both mother and baby, it does not directly correlate with an increased risk of myelomeningocele. Myelomeningocele is a congenital condition related to neural tube development early in pregnancy. The presence of wounds in active Labor may indicate complications such as trauma or infection, but these are not associated with neural tube defects.

Choice C reason: Premature rupture of membranes (PROM) is a condition where the amniotic sac ruptures before Labor begins, potentially leading to preterm birth and infections. While PROM is a concern and requires appropriate medical intervention, it is not directly linked to the development of myelomeningocele. The causes of PROM and neural tube defects like myelomeningocele are different, with PROM often related to issues with the amniotic sac or maternal infections.

Choice D reason: Precipitous Labor, which is an unusually rapid Labor and delivery, can pose risks such as trauma to the birth canal and complications for the newborn, but it is not associated with an increased risk of myelomeningocele. The speed of Labor and delivery is not a contributing factor to neural tube defects. Instead, precipitous Labor is more concerning for potential delivery complications and the need for rapid medical response.

A. Offer a snack and administer another dose. B. Contact the healthcare provider. C. Immediately administer another dose. D. Hold the next dose.

Correct Answer is B

Explanation

Choice A reason: Offering a snack and administering another dose is not appropriate, as it could lead to an overdose if any amount of the medication has been absorbed.

Choice B reason: Contacting the healthcare provider is the safest action. The provider can give specific instructions on how to proceed, including whether another dose should be given and when.

Choice C reason: Immediately administering another dose is not advisable, as it could lead to an overdose if any amount of the medication has been absorbed.

Choice D reason: Holding the next dose without consulting the healthcare provider might result in the child not receiving the necessary medication. Always follow the healthcare provider's instructions.

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The nurse is assessing the urinary output of a patient 4 hours after a caesarean birth. The patient weighs 68 kg and the indwelling catheter bag measures 125 mL of urine. Which action will the nurse include in the plan of care?

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