A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours.At 6 hours post-partum, the client is anxious and restless.
On further assessment, a large perineal hematoma is seen.
She is unable to urinate.
After notifying the physician, the nurse should plan to:
Insert a Foley catheter.
Instruct the client on using a Sitz Bath when she voids.
Monitor the fundal height.
Apply a heating pad to the area.
The Correct Answer is A
Choice A rationale
Inserting a Foley catheter can relieve the bladder and provide an opportunity to monitor urinary output, which is essential for assessing the patient's condition with a perineal hematoma.
Choice B rationale
A Sitz bath may help with pain relief and hygiene but does not address the immediate concern of urinary retention and assessment for injury.
Choice C rationale
Monitoring the fundal height is important but does not address the urgent need to relieve the patient's inability to urinate.
Choice D rationale
Applying a heating pad to the area may help with pain, but it does not address the immediate problem of urinary retention due to the hematoma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Abnormal respiratory assessment findings, such as increased respiratory rate or difficulty breathing, could indicate respiratory distress or infection and should be reported to the provider for immediate evaluation.
Choice B rationale
Hemoglobin level is a critical indicator of blood loss and overall oxygen-carrying capacity. A low level postpartum could suggest significant blood loss or anemia and requires reporting.
Choice C rationale
A heart rate of 106/min is higher than normal and could indicate underlying issues such as pain, anxiety, or hemorrhage. It should be reported to the provider for further assessment.
Choice D rationale
A constant trickle of blood at the vagina could indicate ongoing bleeding from a laceration or retained placental fragments, requiring immediate attention and intervention by the provider. .
Correct Answer is A
Explanation
Choice A rationale
Asking if the client has considered harming her newborn is a priority to assess for potential postpartum depression or psychosis, which require immediate intervention. .
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