A nurse is assessing a client who is 8 hour postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate?
moderate lochia rubra
fundus 3 fingerbreadths above the umbilicus
moderate swelling of the labia
blood pressure 130/84
The Correct Answer is B
A. Moderate lochia rubra is an expected finding in the early postpartum period as the uterus sheds decidual tissue and blood. This finding alone does not specifically indicate bladder distention or urinary retention.
B. A fundus positioned above the umbilicus in the early postpartum period suggests uterine displacement, commonly caused by a distended bladder. Bladder fullness prevents effective uterine contraction and can elevate and deviate the fundus.
C. Moderate labial swelling is common after vaginal delivery due to tissue trauma and vascular congestion. While it may cause discomfort with voiding, it does not indicate the physiologic need to urinate.
D. A blood pressure of 130/84 is slightly elevated but can be normal postpartum due to pain, fluid shifts, or stress. This vital sign change is not associated with bladder distention or urinary retention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Have the primary care physician for the child sign the consent form: The primary care physician cannot legally provide consent for an emergent surgical procedure unless they are acting as the attending surgeon with proper legal authority. This may delay care.
B. Delay medical care until the child's next of kin can be contacted: Delaying emergency surgery in a child with suspected appendicitis can lead to complications such as perforation, peritonitis, or sepsis. Immediate intervention takes priority over obtaining consent when parents are unreachable.
C. Document failed attempts to obtain consent to allow emergency care: In emergencies where life or health is at risk, care can proceed without parental consent under implied consent laws. Thorough documentation of attempts to reach the parents protects the healthcare team legally while allowing the child to receive timely, necessary care.
D. Have the babysitter sign the consent form even if she does not have signed papers to do so: A babysitter does not have legal authority to consent for surgery unless formally designated by a parent or legal guardian. Signing without proper authority could create legal and ethical issues.
Correct Answer is B
Explanation
A. September 17th, 2017: Calculating EDD by subtracting three months from the LMP and adding seven days would place the date earlier than the accurate estimate. This does not account correctly for the standard adjustment used in Nägele’s Rule.
B. September 24th, 2017: Nägele’s Rule estimates the EDD by taking the first day of the last menstrual period, subtracting three months, and adding seven days. Starting from December 17th, 2016, subtracting three months gives September 17th, 2016, then adding seven days results in September 24th, 2017, providing the correct estimated delivery date.
C. October 10th, 2016: This date is inconsistent with gestational length calculations. It falls too early relative to the standard 280-day pregnancy duration and does not follow Nägele’s Rule calculations.
D. October 24th, 2017: This date overestimates gestation length by approximately one month. Adding seven days to the correct calculation places the EDD in late September rather than late October, making it inaccurate according to standard obstetric estimation.
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