A nurse is assessing a client who is 8 hours postpartum and multiparous.
Which of the following findings should alert the nurse to the client’s need to urinate?
Fundus three fingerbreadths above the umbilicus
Blood pressure 130/84 mm Hg
Moderate lochia rubra
Moderate swelling of the labia
The Correct Answer is A
The correct answer is Choice A
Choice A rationale: A distended bladder can displace the uterus upward and to the side, preventing proper uterine involution and increasing risk of postpartum hemorrhage.
Choice B rationale: Blood pressure of 130/84 mm Hg is within normal postpartum range and does not indicate urinary retention or bladder distention.
Choice C rationale: Moderate lochia rubra is expected postpartum and reflects normal uterine shedding, not urinary status.
Choice D rationale: Moderate labial swelling may occur from delivery trauma but does not directly indicate bladder fullness or urinary retention.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Preparing the client for an emergency cesarean birth is an important step, but it is not the first action the nurse should take.
The immediate priority is to relieve pressure on the cord to prevent or alleviate cord compression.
Choice B rationale:
Covering the cord with a sterile, moist saline dressing is done to prevent drying of the cord and to maintain blood flow.
However, this is not the first action to take. The priority is to relieve cord compression by changing the client’s position.
Choice C rationale:
While it is important to explain to the client what is happening, this should not be the first action. The nurse’s priority is to
ensure the safety of the mother and baby, which involves immediate interventions to relieve cord compression.
Choice D rationale:
Placing the client in a knee-chest or Trendelenburg position is the first action the nurse should take. This position helps to
reduce pressure on the cord, which can improve blood flow to the fetus. It is a critical intervention that can prevent serious
complications such as fetal hypoxia.
Correct Answer is A
Explanation
The correct answer is Choice A
Choice A rationale: Uterine atony is the leading cause of postpartum hemorrhage. Assessing fundal tone identifies if the uterus is boggy and requires massage to stimulate contraction and reduce bleeding.
Choice B rationale: Vaginal examination may identify trauma or retained tissue, but it is not the first-line assessment. Initial nursing action focuses on uterine tone before escalating to provider intervention.
Choice C rationale: Vital signs help detect hypovolemia or shock but do not address the bleeding source. Fundal assessment precedes vitals to determine if bleeding is due to uterine atony.
Choice D rationale: A full bladder can displace the uterus and worsen bleeding, but this is assessed after fundal tone. Fundus check is prioritized to identify and treat uterine atony immediately.
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