A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?
Offer the client a sitz bath.
Insert a urinary catheter.
Assist the client to the bathroom.
Pour warm water over the client's perineum.
The Correct Answer is C
Choice A rationale:
Offering the client a sitz bath may provide some relief, but it does not address the underlying issue of bladder distention. The priority is to address the bladder distention directly.
Choice B rationale:
Inserting a urinary catheter is not the first-line intervention for bladder distention after vaginal birth. Catheterization carries a risk of infection and trauma, so it should only be done if other interventions are not effective.
Choice C rationale:
Assisting the client to the bathroom is the first action the nurse should take. Bladder distention can occur after birth due to the pressure on the bladder during labour and birth. Encouraging the client to empty her bladder will relieve the distention and promote comfort.
Choice D rationale:
Pouring warm water over the client's perineum might provide some comfort, but it does not address the bladder distention itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choiceA. Continue to monitor the client.
Choice A rationale:
Early decelerations are typically benign and are caused by fetal head compression during contractions.They usually do not require any specific intervention other than continued monitoring to ensure they remain early decelerations and do not progress to more concerning patterns.
Choice B rationale:
Discontinuing oxytocin is not necessary for early decelerations, as they are not indicative of fetal distress.Oxytocin would be discontinued if there were signs of more severe decelerations or other complications.
Choice C rationale:
Assisting the client to lay on her right side is not specifically required for early decelerations.This position change is more commonly used for variable or late decelerations to improve uteroplacental blood flow.
Choice D rationale:
Administering oxygen at 8 L/min per mask is not needed for early decelerations.Oxygen is typically reserved for situations where there is evidence of fetal hypoxia or distress.
Correct Answer is A
Explanation
Choice A rationale:
Determining gestational age in the first trimester is a common and important use of ultrasound. It helps confirm the estimated due date and monitor the fetus's growth and development.
Choice B rationale:
Performing a biophysical profile in the first trimester is not a common use of ultrasound. Biophysical profiles are usually performed in the second or third trimester to assess fetal well-being.
Choice C rationale:
Observing placental maturity in the first trimester is not a standard use of ultrasound. Placental maturity is typically assessed later in pregnancy, especially in the third trimester.
Choice D rationale:
Detecting intrauterine growth restriction in the first trimester is not a primary use of ultrasound. Intrauterine growth restriction is more commonly assessed in the later stages of pregnancy when fetal growth is a concern.
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