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. Moderate alcohol intake is not a contraindication to COC use.
B. Breastfeeding in the first 6 weeks postpartum is a contraindication to combined oral contraceptives because estrogen can reduce milk supply and increase the risk of thrombosis.
C. High body weight is not an absolute contraindication, though efficacy may be reduced.
D. Age 25 alone is not a contraindication to COCs.

A. Instruct the parent to avoid eye contact with the newborn during feeding. B. Weigh the newborn daily. C. Plan to administer naloxone. D. Instruct the parent to avoid breastfeeding E. Maintain a low stimulation environment F. Swaddle the newborn with flexed extremities. G. Perform Ballard newborn screening each shift.

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

Explanation

A. Instruct the parent to avoid eye contact with the newborn during feeding – This is not recommended. While overstimulation should be minimized, gentle eye contact and bonding are still encouraged during feeding to promote attachment.

B. Weigh the newborn daily – Weight loss and feeding difficulties are common in NAS. Daily weight monitoring is essential to evaluate nutritional status and fluid balance.

C. Plan to administer naloxone – Naloxone is contraindicated in opioid-exposed neonates because it can precipitate acute withdrawal and seizures.

D. Instruct the parent to avoid breastfeeding – Breastfeeding is generally encouraged unless the mother is using illicit substances or is HIV-positive. Methadone is not a contraindication for breastfeeding.

E. Maintain a low stimulation environment – NAS newborns are easily overstimulated. A quiet, dimly lit environment helps reduce symptoms like irritability and tremors.

F. Swaddle the newborn with flexed extremities – Swaddling provides comfort and containment, helping to reduce stress responses in NAS infants.

G. Perform Ballard newborn screening each shift – The Ballard score is used once to assess gestational age and is not repeated every shift.

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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

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A nurse is assessing a client who is requesting a combined oral contraceptive (COC). Which of the following findings should indicate to the nurse that the client has a contraindication to COC use?

Correct Answer is B

Explanation

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

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