Which assessment technique would provide the most useful data when the nurse is concerned about possible urinary retention?
Auscultate an area six inches below the umbilicus.
Observe the appearance of the patient’s urine.
Palpate the area above the pubic symphysis.
Measure the girth of the patient’s lower abdomen.
The Correct Answer is C
Choice A rationale
Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.
Choice B rationale
Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.
Choice C rationale
Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.
Choice D rationale
Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A rationale
Methylergonovine is used after childbirth to help control bleeding and improve muscle tone in the uterus. Administering 0.2 mg of methylergonovine IM can help to control postpartum hemorrhage in this patient.
Choice B rationale
Notifying the primary healthcare provider is crucial in this situation. The healthcare provider needs to be aware of the patient’s condition and the interventions being initiated.
Choice C rationale
Inserting a straight catheter can help to manage urinary retention, which could be a potential issue given the patient’s prolonged labor and use of epidural anesthesia.
Choice D rationale
Massaging the fundus until it is firm can help to stimulate uterine contractions, which can control bleeding and prevent postpartum hemorrhage.
Choice E rationale
Counting saturated pads per hour can help to monitor the amount of bleeding and assess the effectiveness of the interventions.
Correct Answer is C,A,D,B
Explanation
Step 1: Observe breathing patterns. Respiratory depression is a critical symptom of myxedema coma that requires immediate attention.
Step 2: Measure body temperature. Hypothermia is a common symptom of myxedema coma and can provide important information about the severity of the patient’s condition.
Step 3: Assess blood pressure. Hypotension can occur in myxedema coma and can indicate the severity of the patient’s condition.
Step 4: Palpate for pedal edema. While this can be a symptom of hypothyroidism, it is not typically a primary concern in a patient showing signs of myxedema coma.
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