The nurse is caring for a client on the postpartum unit who had a vaginal delivery with epidural anesthesia 2 hours ago. 1. The client presses the call light and tells the nurse she needs to use the bathroom 2. The nurse arrives in the client's room 5 minutes later 3.
The client is getting out of bed alone What is the best response by the nurse?
Suggest catheterizing her this time to prevent the possibility of fainting
Ask the client to lie back down and get her a bedpan
Assist the client to the bathroom
Have the client sit dangling her legs over the side of the bed for 5 minutes
The Correct Answer is C
A. Catheterization may not be necessary at this time and can be uncomfortable for the client.
B. Using a bedpan may not be the most comfortable option for the client, who likely wants to ambulate.
C. Assisting the client to the bathroom is the best response to ensure her safety and prevent falls.
D. Dangling the legs over the side of the bed is not necessary in this situation and may not address the client's need to use the bathroom.
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Related Questions
Correct Answer is B
Explanation
A. Client 4, who delivered 8 hours ago, having a fundus at the umbilicus is within the expected range for a client at this stage postpartum.
B. Client 2, two days postpartum with a fundus 2 cm above the umbilicus, is suggestive of uterine subinvolution, as the fundus should be descending, not rising, after delivery.
C. Client 1, three days postpartum with a fundus 3 cm below the umbilicus, is within the expected range for the postpartum period.
D. Client 3, one day postpartum with a fundus 1 cm below the umbilicus, is within the expected range for the postpartum period.
Correct Answer is A
Explanation
A. Changing the client's position, especially if there's a cord compression causing variable decelerations, is a priority intervention to alleviate the decelerations.
B. Informing the primary care provider is important, but immediate action to address the decelerations should be taken first.
C. Vaginal examination is not the immediate priority when variable decelerations are observed; interventions to improve fetal oxygenation are more critical.
D. Continuous monitoring is essential, but addressing the cause of the variable decelerations by changing the client's position is the immediate action.
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