A nurse is caring for a client who had a vaginal birth 4 hr ago and had a 3rd-degree perineal laceration with repair. The client has been unable to void since giving birth. Which of the following findings indicates the need for straight catheterization?

The client rates perineal pain a 3 on a scale of 0 to 10.

The client's fundus is boggy and deviated to the right

The client has a moderate amount of lochia rubra

The client's perineum is ecchymotic with moderate edema

Answer and Explanation

The Correct Answer is B

A. A pain rating of 3 is relatively mild and does not indicate urinary retention.
B. A boggy, deviated fundus suggests bladder distention, which can occur when the bladder is full and displaces the uterus. This is an indication for straight catheterization to relieve urinary retention.
C. Moderate lochia rubra is expected 4 hours postpartum and does not indicate urinary retention.
D. While edema and bruising are common after delivery, they do not alone indicate a need for catheterization.

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Correct Answer is ["B","D","E"]

Explanation

A. Polyhydramnios is not a complication of amniocentesis; it is a condition related to excess amniotic fluid.
B. Preterm labor can be triggered by the procedure due to uterine irritation or infection.
C. Urinary tract infection is unrelated to amniocentesis unless catheterization was performed, but it is not a direct complication.
D. Amnionitis (intra-amniotic infection) is a serious complication resulting from infection introduced during the procedure.
E. Leakage of amniotic fluid can occur if the amniotic sac is punctured improperly or does not seal properly after the procedure.

A. "Your baby needs to be repositioned every 2 to 3 hours while under the lights." B. "Your baby's eyes will be covered with an eye shield during therapy." C. "Avoid applying lotion to your baby's skin." D. "Keep a hat on your baby during treatment." E. "We will give your baby glucose water between breast feedings. F. "Bilirubin is primarily excreted through the stool." G. The treatment lights can cause a transient skin rash on your baby." H. The treatment lights emit a significant amount of ultraviolet radiation.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"},"H":{"answers":"B"}}

Explanation

Statement	Include	Not Include
"Your baby needs to be repositioned every 2 to 3 hours while under the lights."	✅
"Your baby's eyes will be covered with an eye shield during therapy."	✅
"Avoid applying lotion to your baby's skin."	✅
"Keep a hat on your baby during treatment."		✅
"We will give your baby glucose water between breast feedings.		✅
"Bilirubin is primarily excreted through the stool."	✅
The treatment lights can cause a transient skin rash on your baby."	✅
The treatment lights emit a significant amount of ultraviolet radiation.		✅

Repositioning every 2 to 3 hours exposes different skin areas to light, enhancing bilirubin breakdown and preventing pressure sores.
Eye shields protect the newborn’s eyes from damage caused by bright phototherapy lights.
Avoiding lotion prevents skin irritation or burns and ensures effective light penetration during treatment.
Keeping a hat on blocks light exposure to the scalp, reducing the effectiveness of phototherapy.
Glucose water is not recommended; feeding with breast milk or formula helps promote bilirubin elimination through stools.
Bilirubin is mainly excreted through the stool after being converted into a water-soluble form by phototherapy.
Phototherapy can cause a mild, temporary rash, which is harmless but important to inform parents about.
Phototherapy lights emit blue light, not harmful ultraviolet radiation, making them safe for newborn treatment.

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A nurse is caring for a client who had a vaginal birth 4 hr ago and had a 3rd-degree perineal laceration with repair. The client has been unable to void since giving birth. Which of the following findings indicates the need for straight catheterization?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client following an amniocentesis. Which of the following findings should the nurse recognize as complications? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is caring for a newborn Exhibits Which of the following statements should the nurse include in the plan of care for the baby

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"A"},"H":{"answers":"B"}}

Explanation

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