A nurse is performing a postpartum assessment on a patient 2 hr following delivery of a healthy newborn. Which finding indicates the patient's bladder is distended?
The lochia is small with scant clots
The fundus is at the umbilicus and midline
The lochia is moderate with no clots
The fundus is deviated to the right at U+2
The Correct Answer is D
A. The lochia is small with scant clots is incorrect because scant lochia is a normal finding in the immediate postpartum period. Scant lochia reflects the normal shedding of the uterine lining and is not affected by bladder distention. While abnormal lochia patterns can indicate complications such as retained placental fragments or infection, small, scant lochia alone does not suggest a distended bladder.
B. The fundus is at the umbilicus and midline is incorrect because a firm, midline fundus at the umbilicus is considered a normal finding 2 hours postpartum. This indicates that the uterus is contracting appropriately and that there is no interference from bladder distention. A normal fundal position rules out bladder distention as a cause for uterine displacement.
C. The lochia is moderate with no clots is incorrect because moderate lochia is also within the expected range for 2 hours postpartum and represents normal uterine bleeding as the uterus continues involution. This finding does not indicate bladder distention, although excessive bleeding or clots could signal uterine atony or retained tissue.
D. The fundus is deviated to the right at U+2 is correct because a lateral displacement of the fundus, most commonly to the right, is a hallmark sign of bladder distention. The full bladder physically pushes the uterus out of midline, preventing adequate contraction. If left unrelieved, this can increase the risk of uterine atony and postpartum hemorrhage. The nurse should assist the patient to void or catheterize if necessary, then reassess the fundal position to ensure the uterus is firm and midline.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Barking cough and inspiratory stridor, especially at night is incorrect because this is characteristic of croup, a respiratory condition, not tetralogy of Fallot. Tetralogy of Fallot primarily affects cardiac blood flow, not the upper airway.
B. Bradycardia and hypotension following minor activity or mild stress is incorrect because children with tetralogy of Fallot typically develop tachycardia in response to hypoxia or stress, rather than bradycardia. Hypotension is not a hallmark sign unless there is shock or severe complications.
C. Cyanosis that worsens during crying or feeding, often relieved by squatting is correct because children with tetralogy of Fallot have right-to-left shunting due to the combination of ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. This shunting reduces pulmonary blood flow, leading to cyanosis, which often becomes more pronounced during periods of increased oxygen demand, such as crying or feeding. Squatting increases systemic vascular resistance, temporarily reducing the shunt and improving oxygenation, which is known as a “Tet spell” relief maneuver.
D. Peripheral edema and hepatomegaly during exertion or prolonged play is incorrect because these signs are more typical of heart failure rather than tetralogy of Fallot in a child without chronic severe heart failure. Tetralogy of Fallot presents primarily with cyanosis and hypoxic spells.
Correct Answer is C
Explanation
A. Hydralazine is incorrect because it is an antihypertensive used to lower blood pressure in preeclampsia or eclampsia, but it does not reverse magnesium sulfate toxicity, which is the immediate concern given the symptoms of respiratory depression, oliguria, and absent deep tendon reflexes.
B. Methylergonovine is incorrect because it is a uterotonic used to control postpartum hemorrhage. It is not indicated for magnesium toxicity and would not address the life-threatening respiratory and neuromuscular effects of magnesium sulfate overdose.
C. Calcium gluconate is correct because it is the antidote for magnesium sulfate toxicity. Symptoms of toxicity include respiratory depression (RR <12), oliguria (<30 mL/hr), absent deep tendon reflexes, and eventually cardiac arrhythmias or arrest. Administering 10 mL of 10% calcium gluconate IV over 3–5 minutes can rapidly reverse neuromuscular and cardiac effects while supportive care (e.g., stopping magnesium infusion and monitoring) is continued.
D. Narcan is incorrect because it is an opioid antagonist used to reverse opioid overdose. It has no effect on magnesium sulfate toxicity and would not address the neuromuscular or respiratory compromise in this patient.
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