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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
B. Hand-to-mouth movements are an early hunger cue as the newborn tries to self-soothe or indicate readiness to feed.
C. Rooting reflex is a classic early sign where the newborn turns their head toward the stimulus (like a nipple) indicating hunger.
D. Sucking motions suggest the newborn is preparing or ready to feed.
A. Consistent crying is a late hunger cue and can indicate distress if earlier cues are missed.
E. The Babinski reflex is a neurological reflex unrelated to hunger cues.
Correct Answer is D
Explanation
A. Assessing cervical dilation is contraindicated due to risk of worsening bleeding with abruptio placenta.
B. Vaginal swabs for ferning test are used to assess rupture of membranes, not abruptio placenta.
C. Administering oxytocin can increase uterine contractions and worsen placental separation, so it is contraindicated.
D. Monitoring fetal heart rate tracings is essential to assess fetal well-being in cases of abruptio placenta.
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