A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Fundus palpable to right of midline

Less than 2.5 cm of rubra lochia on perineal pad

Client report of increased thirst

Client report of frequent uterine contractions

Answer and Explanation

The Correct Answer is A

A.   A fundus palpable to the right of midline may indicate a distended bladder pushing the uterus to the side, and it requires intervention to promote bladder emptying.
B.   Less than 2.5 cm of rubra lochia on a perineal pad is a normal finding in the early postpartum period.
C. Increased thirst is not directly indicative of bladder distention.
D.   Frequent uterine contractions are expected in the postpartum period and do not necessarily indicate bladder distention.

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Correct Answer is A

Explanation

A. Breast milk typically comes in 3 to 5 days postpartum.
B. This timeline is too early for the onset of mature breast milk.
C. This timeline is too late for the onset of mature breast milk.
D. This timeline is too late for the onset of mature breast milk.

A. Blot the perineal area dry after cleansing. B. Perform hand hygiene before and after voiding. C. Apply ice packs to the perineal area several times daily. D. Clean the perineal area from front to back. E. Wash the perineal area using a squeeze bottle of warm water after each voiding.

Correct Answer is ["A","B","D","E"]

Explanation

A. Blotting the perineal area dry helps prevent moisture retention, reducing the risk of infection.
B. Performing hand hygiene before and after voiding helps prevent the introduction of bacteria into the perineal area.
C. Applying ice packs may help reduce swelling but is not a routine measure for preventing infection.
D. Cleaning the perineal area from front to back helps prevent the introduction of fecal bacteria into the urethra and vagina.
E. Washing the perineal area using a squeeze bottle of warm water after each voiding helps maintain cleanliness and prevent infection.

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A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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Correct Answer is ["A","B","D","E"]

Explanation

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