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

Explanation

A. A grade 2 placental abruption typically presents with a firm or rigid abdomen due to concealed bleeding, not a soft one.
B. Maternal tachycardia (heart rate 120/min) is expected due to blood loss and compensatory response to hypovolemia.
C. A fetal heart rate of 150/min with moderate variability is a reassuring sign and would not typically be expected in a significant abruption, where fetal distress is more common.
D. Vaginal bleeding from placental abruption is typically painful, and may be concealed. Painless bleeding is more characteristic of placenta previa.

A. Water retention B. Tachycardia C. Seizures D. Hypertension

Correct Answer is D

Explanation

A. Water retention is not a common adverse effect of methylergonovine.
B. Tachycardia is not typically caused by methylergonovine; bradycardia or hypertension is more common.
C. Seizures are not a common side effect of this medication.
D. Hypertension is a known adverse effect of methylergonovine and requires close monitoring, especially in clients with preexisting hypertension.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a grade 2 placental abruption. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is assessing a client who received methylergonovine to treat uterine atony in the fourth stage of labor. Which of the following findings should the nurse identify as an adverse effect of the medication?

Correct Answer is D

Explanation

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