A nurse is caring for a client at 12 hours postpartum who has voided a total of 200 ml. Upon assessment the nurse notes that the bladder is distended. What is the priority intervention by the nurse?
No intervention is needed at this time. 200 ML is adequate output.
Notify the provider immediately of urinary retention.
Notify the provider if the client does not void in 24 hours.
Encourage the client to consume more fluids.
The Correct Answer is B
A. Incorrect. 200 mL of urine in 12 hours is inadequate postpartum output and may indicate urinary retention.
B. Correct. A distended bladder can interfere with uterine involution and increase the risk of postpartum hemorrhage. The provider should be notified, and interventions such as catheterization may be necessary.
C. Incorrect. Waiting 24 hours before intervention is inappropriate when urinary retention is already evident.
D. Encouraging fluids is helpful, but it does not directly address the immediate concern of a distended bladder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. IV fluids may be beneficial but do not directly address the fever.
B. Pyridoxine (Vitamin B6) is used for conditions like nausea in pregnancy, but it is not relevant for fever management.
C. Acetaminophen (Tylenol) is an antipyretic that helps reduce fever and improve comfort. Given the client's elevated temperature, treating the fever is the priority.
D. Zofran is used to manage nausea and vomiting, which is not the primary concern here.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
The nurse should recognize that the client is at risk of postpartum hemorrhage due to polyhydramnios.
Risk:
Postpartum Hemorrhage (PPH): The client has polyhydramnios and multiple gestation, which cause uterine overdistension. Overdistension increases the risk of uterine atony postpartum, a leading cause of PPH. Other contributing factors are the large uterine fibroids and a history of preterm labor.
Probable Cause:
Polyhydramnios: AFI of 30 cm indicates polyhydramnios, which is excess amniotic fluid.
Multiple gestation (twins) is a common cause of polyhydramnios. Polyhydramnios increases the risk of preterm labor, cord prolapse, and PPH.
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