Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void every 2 hours?
Select one:
Frequent voiding encourages sphincter control.
A full bladder impedes oxygen flow to the fetus.
Frequent voiding prevents bruising of the bladder.
A full bladder can impede fetal descent.
The Correct Answer is D
Choice A Reason: Frequent voiding encourages sphincter control. This is an incorrect statement that has no relevance to labor and delivery. Sphincter control refers to the ability to contract and relax the muscles that control urination and defecation. It is not affected by frequent voiding.
Choice B Reason: A full bladder impedes oxygen flow to the fetus. This is an incorrect statement that confuses a full bladder with a prolapsed cord. A prolapsed cord is a condition where the umbilical cord slips through the cervix before the baby and becomes compressed by the fetal head, which can reduce oxygen flow to the fetus. A full bladder does not affect oxygen flow to the fetus.
Choice C Reason: Frequent voiding prevents bruising of the bladder. This is an incorrect statement that exaggerates the effect of a full bladder on the bladder wall. A full bladder may cause some pressure or discomfort on the bladder, but it does not cause bruising or damage.
Choice D Reason: A full bladder can impede fetal descent. This is a correct statement that explains why it is important for the nurse to assess the bladder regularly and encourage the laboring client to void every 2 hours.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Moderate amounts of deep red lochia. This is not a finding that would warrant further investigation, but rather a normal finding for the early postpartum period. Lochia is the vaginal discharge that occurs after delivery, which consists of blood, mucus, and tissue from the uterus. Lochia is usually deep red in color and moderate in amount for the first few days after delivery.
Choice B Reason: Sweating while afebrile. This is not a finding that would warrant further investigation, but rather a common occurrence in the postpartum period. Sweating is a mechanism of thermoregulation that helps the body eliminate excess fluid and electrolytes that were retained during pregnancy. Sweating does not necessarily indicate fever or infection.
Choice C Reason: Voiding 350 mL of blood-tinged urine. This is not a finding that would warrant further investigation, but rather an expected outcome for the postpartum period. Voiding large amounts of urine is normal in the postpartum period, as the body eliminates the excess fluid that was accumulated during pregnancy. Blood-tinged urine may be due to trauma or irritation of the urinary tract during labor or delivery, which usually resolves within a few days.
Choice D Reason: Heart rate of 115 beats/minute. This is because a heart rate of 115 beats/minute is higher than the normal range for an adult, which is 60 to 100 beats/minute. A high heart rate may indicate postpartum hemorrhage, infection, pain, anxiety, or dehydration. The nurse should further assess the client for other signs and symptoms of these conditions and notify the physician if necessary.
Correct Answer is C
Explanation
Choice A Reason: Manifestations of uteroplacental insufficiency. This is an incorrect answer that describes a different condition that affects the fetus, not the mother. Uteroplacental insufficiency is a condition where the placenta fails to deliver adequate oxygen and nutrients to the fetus, which can result in fetal growth restriction, distress, or demise. Uteroplacental insufficiency does not cause shortness of breath, hypoxia, or cyanosis in the mother.
Choice B Reason: Manifestations of prolapsed cord. This is an incorrect answer that refers to another condition that affects the fetus, not the mother. Prolapsed cord is a condition where the umbilical cord slips through the cervix before the baby and becomes compressed by the fetal head, which can reduce oxygen flow to the fetus. Prolapsed cord does not cause shortness of breath, hypoxia, or cyanosis in the mother.
Choice C Reason: Manifestations of anaphylactoid syndrome of pregnancy. This is because anaphylactoid syndrome of pregnancy, also known as amniotic fluid embolism, is a rare and fatal condition where amniotic fluid enters into the maternal bloodstream and causes an allergic reaction, which can lead to respiratory failure, cardiac arrest, coagulopathy, and coma. Anaphylactoid syndrome of pregnancy can occur during or after labor and delivery, especially in cases of NSVD, multiparity, advanced maternal age, or placental abruption.
Choice D Reason: Manifestations of an acute asthmatic episode. This is an incorrect answer that assumes that the mother has a history of asthma or an allergic trigger. Asthma is a chronic inflammatory disorder of the airways that causes wheezing, coughing, chest tightness, and dyspnea. Asthma can be exacerbated by pregnancy or labor, but it is not a common cause of sudden onset respiratory distress in the postpartum period.
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