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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?

A.

Offer the client a sitz bath.

B.

Insert a urinary catheter.

C.

Assist the client to the bathroom.

D.

Pour warm water over the client's perineum.

Answer and Explanation

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. 
 


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Related Questions

Correct Answer is C

Explanation

The correct answer is choice c. Heart rate 72/min.

Choice A rationale:

A blood pressure of 80/50 mm Hg is within the normal range for a full-term newborn.

Choice B rationale:

A respiratory rate of 55/min is also within the normal range for a newborn, which typically ranges from 30 to 60 breaths per minute.

Choice C rationale:

A heart rate of 72/min is significantly lower than the normal range for a newborn, which is typically between 120 to 160 beats per minute. This bradycardia should be reported to the provider as it may indicate an underlying issue.

Choice D rationale:

A temperature of 36.5°C (97.7°F) is within the normal range for a newborn, which is generally between 36.5°C to 37.5°C (97.7°F to 99.5°F).

Correct Answer is C

Explanation

The correct answer is c. Ampicillin.

Rationale:

  • Group B Streptococcus (GBS) B-hemolyticis a bacterium that can colonize the vagina and rectum of pregnant women.While usually harmless to the mother,it can be passed to the newborn during birth and cause serious infections,including pneumonia,meningitis,and sepsis.
  • Ampicillinis thefirst-line antibioticrecommended by the Centers for Disease Control and Prevention (CDC) for theprevention of GBS disease in newborns.It belongs to thepenicillin classof antibiotics,which are highly effective against GBS and generally well-tolerated by pregnant women and newborns.
  • Doxycyclineis not recommended for GBS prophylaxis due to its poor penetration into amniotic fluid and potential for causing tooth discoloration and bone development problems in newborns.
  • Cefotetanis an alternative option for women with penicillin allergy,but ampicillin is still preferred due to its lower cost and broader spectrum of activity against GBS strains.
  • Fluconazoleis an antifungal medication and has no activity against GBS bacteria.

Detailed Rationale for Each Choice:

a. Doxycycline:

  • Rationale against:
    • Poor penetration into amniotic fluid:Doxycycline does not effectively reach the amniotic sac,where the baby is surrounded,and therefore may not adequately protect the newborn from GBS infection.
    • Adverse effects in newborns:Doxycycline can cause tooth discoloration and bone development problems in infants exposed in utero.

b. Cefotetan:

  • Rationale for:
    • Alternative for penicillin allergy:Cefotetan is a cephalosporin antibiotic effective against GBS and can be used in women with penicillin allergy.
  • Rationale against:
    • Second-line option:Ampicillin is the preferred choice due to its lower cost and broader spectrum of activity against GBS strains.

c. Ampicillin:

  • Rationale for:
    • First-line antibiotic:Ampicillin is the CDC-recommended first-line antibiotic for GBS prophylaxis due to its:
      • High effectiveness against GBS:Ampicillin has a broad spectrum of activity against GBS strains.
      • Good safety profile:Ampicillin is generally well-tolerated by pregnant women and newborns.
      • Cost-effectiveness:Ampicillin is a relatively inexpensive antibiotic compared to other options.

d. Fluconazole:

  • Rationale against:
    • Antifungal medication:Fluconazole is an antifungal medication and has no activity against GBS,which is a bacterium.

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