A nurse is assessing a client postpartum.Which of the following findings should alert the nurse to the client's need to urinate?
Large amount of swelling of the labia.
Fundus three fingerbreadths above the umbilicus.
Moderate lochia rubra.
Swelling of the ankles and feet.
The Correct Answer is B
Choice A rationale
Swelling of the labia postpartum can be a common occurrence due to trauma during delivery and does not specifically indicate the need to urinate. The swelling usually subsides with time and proper postpartum care.
Choice B rationale
A fundus positioned three fingerbreadths above the umbilicus can indicate a full bladder. The bladder's distension prevents the uterus from contracting properly, which can lead to postpartum hemorrhage and other complications, hence the need for the client to urinate.
Choice C rationale
Moderate lochia rubra is a normal finding in the postpartum period and does not specifically indicate the need to urinate. Lochia changes in color and amount over the postpartum weeks as the uterus heals.
Choice D rationale
Swelling of the ankles and feet, or edema, is common postpartum due to the body's adjustment to changes in blood volume and fluid shifts. It does not directly indicate the need to urinate.
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 F
Explanation
Choice A rationale
Abnormal stool patterns can be a sign of various issues in newborns, but they do not align with the vital signs presented. The vital signs suggest a more systemic issue rather than one isolated to digestive patterns.
Choice B rationale
While temperature regulation is critical in newborns, especially those who are preterm, the vital signs presented suggest a broader systemic issue. The symptoms do not align with isolated temperature dysregulation.
Choice C rationale
Feeding difficulties can be a sign of neonatal abstinence syndrome but are not directly reflected in the vital signs presented. Neonatal Abstinence Syndrome (NAS) encompasses a range of withdrawal symptoms due to exposure to drugs in utero, not just feeding issues.
Choice D rationale
While extremity issues can be present in various neonatal conditions, they do not align with the systemic symptoms shown in the vital signs. NAS impacts multiple body systems and would present more generalized symptoms.
Choice E rationale
Hypoglycemia can present with some of these vital signs, such as a rapid heart rate, but it does not explain all the symptoms like increased respiratory rate and temperature dysregulation. It is a condition that requires monitoring but is not the primary diagnosis suggested here.
Choice F rationale
Neonatal Abstinence Syndrome is consistent with the vital signs: elevated heart rate, increased respiratory rate, and lower temperature. NAS results from withdrawal from substances the newborn was exposed to in utero and affects multiple body systems, explaining the range of symptoms.
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