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A nurse is caring for a client who has not voided since giving birth vaginally 10 hours ago. Which of the following actions should the nurse take?

A.

Palpate the client's bladder in 1 hour.

B.

Place the client's hands in a bowl of cold water.

C.

Have the client listen to running water while on the toilet.

D.

Perform effleurage over the client's lower abdomen.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Palpate the client's bladder in 1 hour: Waiting another hour to assess the bladder delays intervention. At 10 hours postpartum with no void, immediate action is needed to stimulate voiding or assess for urinary retention.

B. Place the client's hands in a bowl of cold water: This technique is more commonly used in children and is less effective in stimulating voiding in postpartum adults. It is not a first-line strategy in this context.

C. Have the client listen to running water while on the toilet: This is a noninvasive and effective method to stimulate the urge to void by triggering the micturition reflex. It can help relax pelvic muscles and encourage urination postpartum.

D. Perform effleurage over the client's lower abdomen: Effleurage is a light massage technique used primarily for labor pain management. It is not a recognized or effective method to promote urination in postpartum care.


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Related Questions

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Explanation

Rationale:

  • Platelet count: A low platelet count (<100,000/mm³) is a hallmark of HELLP syndrome but can also appear in severe preeclampsia. Therefore, thrombocytopenia supports both diagnoses.
  • Alanine aminotransferase (ALT): Elevated ALT indicates hepatic involvement due to hepatocellular injury, which is a defining feature of HELLP syndrome but not required for preeclampsia diagnosis.
  • Blood pressure: Severe hypertension (≥160/110 mm Hg), as seen in this client, is diagnostic of severe preeclampsia. It may also be present in HELLP syndrome due to overlapping pathophysiology.
  • Hemoglobin: Low hemoglobin can reflect hemolysis, which is part of the HELLP acronym (Hemolysis, Elevated Liver enzymes, Low Platelets). Preeclampsia does not typically present with anemia unless HELLP develops.

Correct Answer is B

Explanation

Rationale:

A. "I will avoid strenuous exercise.": Physical activity, including regular moderate exercise like walking, actually helps stimulate bowel function. Avoiding exercise may worsen constipation rather than prevent it.

B. "I will increase my intake of high-fiber foods.": A high-fiber diet supports regular bowel movements by increasing stool bulk and promoting peristalsis. This is a key strategy for preventing opioid-induced constipation.

C. "I will take a bulk-forming laxative every day.": Bulk-forming laxatives can be helpful, but daily use should be discussed with a provider, as they can worsen constipation if fluid intake is insufficient. Dietary changes are usually the first recommended step.

D. "I will limit my fluid intake to 1 liter per day.": Limiting fluid intake can lead to dehydration and hard stools, worsening constipation. Adequate hydration is essential to help fiber work effectively and support regular bowel function.

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