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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Apply a warm compress: Warm compresses are used to relieve muscle tension or promote circulation, but immediately after an episiotomy, warmth can increase swelling and discomfort rather than provide pain relief.
B. Apply ice pad or pack: Applying an ice pack to the perineal area immediately postpartum helps reduce swelling, inflammation, and discomfort at the episiotomy site. Cold therapy provides local vasoconstriction, which minimizes edema and offers pain relief during the first 24 hours.
C. Vital signs every two hours: Monitoring vital signs is important for detecting systemic complications, but it does not directly address perineal pain, edema, or wound care for an episiotomy.
D. Early ambulation: Early ambulation promotes circulation and reduces the risk of thromboembolism, but it should be initiated only after pain is managed and the patient can safely mobilize without exacerbating perineal discomfort.
Correct Answer is C
Explanation
A. Increase the progress of labor: Magnesium sulfate does not stimulate uterine contractions or accelerate labor. Its pharmacologic action primarily affects neuromuscular excitability rather than uterine contractility.
B. Decrease blood pressure: While magnesium sulfate may have a mild vasodilatory effect, it is not used as a primary antihypertensive in preeclampsia. Blood pressure management typically involves medications such as labetalol, hydralazine, or nifedipine.
C. Prevent seizures: Magnesium sulfate acts as a central nervous system depressant and blocks neuromuscular transmission, reducing the risk of eclampsia by preventing seizure activity in clients with severe preeclampsia. It is the drug of choice for seizure prophylaxis during pregnancy.
D. Prevent contractions: Although magnesium sulfate has some tocolytic properties at high doses, its standard use in preeclampsia is for seizure prevention rather than inhibition of labor, and it is not the first-line agent for stopping preterm contractions.
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