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 D
Explanation
A. Pulse is 90 beats per minute is incorrect because a normal heart rate does not contraindicate methylergonovine. The medication’s primary cardiovascular effect is on vascular smooth muscle, not directly on heart rate.
B. Pulse is 110 beats per minute is incorrect because mild tachycardia alone is not a contraindication. However, the nurse should monitor heart rate during administration, especially if hypotension or other complications arise.
C. Blood pressure of 120/70 is incorrect because this is a normal blood pressure and indicates it is safe to give the medication.
D. Blood pressure of 150/90 is correct because hypertension is a contraindication for methylergonovine. Administering the drug to a hypertensive patient can precipitate severe hypertension, stroke, myocardial infarction, or other cardiovascular complications. The nurse must hold the medication, notify the healthcare provider, and implement alternative measures for postpartum bleeding management.
Correct Answer is D
Explanation
A. Quickening experienced by the patient is incorrect because quickening (the first perception of fetal movement by the mother) is considered a presumptive sign of pregnancy, not a positive sign. While it suggests pregnancy, it can be mistaken for gastrointestinal activity.
B. Patient reports of a positive pregnancy test is incorrect because this is a probable sign of pregnancy. Laboratory tests detecting human chorionic gonadotropin (hCG) are more reliable than presumptive signs, but they can occasionally give false positives (e.g., due to certain medications or medical conditions).
C. Braxton Hicks contractions felt by the patient is incorrect because these are also presumptive or possible signs of pregnancy. They indicate uterine activity, but they do not confirm the presence of a fetus.
D. Fetal movement palpated by the provider is correct. This is considered a positive sign of pregnancy, as only a developing fetus can cause these movements to be felt by an examiner. Other positive signs include visualization of the fetus on ultrasound and auscultation of the fetal heartbeat. Positive signs provide definitive confirmation of pregnancy, distinguishing them from presumptive or probable signs.
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