A nurse in the emergency department is assessing a young adult client who was administered a hypotonic IV fluid bolus for rehydration after collapsing at an athletic event. Which of the following findings indicates the client is experiencing water intoxication?

Hypernatremia

Weak pulses

Exaggerated reflexes

Muscle weakness

Answer and Explanation

The Correct Answer is D

A) Hypernatremia refers to elevated sodium levels in the blood and is not consistent with water intoxication. In water intoxication, hyponatremia (low sodium levels) is more likely due to dilutional effects from excess water intake.

B) Weak pulses are not specific findings associated with water intoxication. While fluid overload can lead to cardiovascular complications, such as hypertension and bounding pulses, weak pulses are not typically indicative of water intoxication.

C) Exaggerated reflexes are not characteristic findings of water intoxication. Instead, neurological symptoms such as confusion, headache, and seizures may occur due to cerebral edema resulting from water intoxication.

D) Muscle weakness is a potential manifestation of water intoxication due to hyponatremia, which can lead to changes in osmolarity and cellular function. Hyponatremia can cause neurological symptoms such as muscle weakness, lethargy, and seizures. As water moves into cells, it can disrupt cellular function and lead to symptoms of cellular swelling. Therefore, muscle weakness is a concerning finding in the context of suspected water intoxication.

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Correct Answer is C

Explanation

A) Increase the client's fluid intake:

While maintaining adequate hydration is essential for postpartum recovery, it is not the priority intervention in this situation. The client's increased blood loss requires immediate attention to prevent complications such as hemorrhage.

B) Prepare to administer oxytocic medication:

Oxytocic medication may be indicated to stimulate uterine contractions and control bleeding in postpartum clients experiencing excessive bleeding. However, before administering medication, assessing the client's condition and determining the cause of bleeding is necessary to ensure appropriate intervention.

C) Palpate the client's uterine fundus:

This is the priority nursing intervention. Saturating two perineal pads with blood in a 30-minute period suggests excessive bleeding, which could be due to uterine atony or other postpartum complications. Palpating the uterine fundus helps assess for uterine tone, position, and any signs of uterine atony. If the fundus is boggy or deviated from the midline, it indicates uterine atony and requires immediate intervention.

D) Assist the client on a bedpan to urinate:

While assisting the client with urination is important for comfort and prevention of urinary retention, it is not the priority intervention in this situation. Assessing and managing the cause of excessive bleeding take precedence to prevent further complications.

A. Less than 2.5 cm of rubra lochia on perineal pad B. Client report of increased thirst C. Fundus palpable to right of midline D. Client report of frequent uterine contractions

Correct Answer is C

Explanation

A) Less than 2.5 cm of rubra lochia on perineal pad:

The amount of lochia on the perineal pad is an indicator of postpartum bleeding and uterine involution but does not specifically indicate bladder distention.

B) Client report of increased thirst:

Increased thirst may indicate dehydration, which can occur postpartum, but it is not a specific sign of bladder distention.

C) Fundus palpable to right of midline:

This finding suggests bladder distention. A full bladder can displace the uterus to the right side of the midline. Bladder distention can hinder uterine contractions and increase the risk of postpartum hemorrhage. Emptying the bladder can help the uterus contract effectively and prevent complications.

D) Client report of frequent uterine contractions:

Frequent uterine contractions are expected in the immediate postpartum period as the uterus undergoes involution. However, this finding does not specifically indicate bladder distention.

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A nurse in the emergency department is assessing a young adult client who was administered a hypotonic IV fluid bolus for rehydration after collapsing at an athletic event. Which of the following findings indicates the client is experiencing water intoxication?

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