A nurse on a postpartum unit is caring for a group of clients. Which of the following clients is the nurse’s priority?
A client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus.
A client who is 3 days postpartum and has not had a bowel movement since prior to admission.
A client who is 4 days postpartum and has lochia serosa.
A client who is 1 day postpartum and has not voided in 8 hr.
The Correct Answer is D
A client who is 1 day postpartum and has not voided in 8 hr. This client is at risk of urinary retention, bladder distension, and infection due to the effects of epidural anesthesia, perineal trauma, and fluid shifts after delivery. The nurse should assess the client’s bladder and catheterize if necessary.
Choice A is wrong because a client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus is showing a normal finding.
The fundus should descend about 1 to 2 cm per day after delivery and be nonpalpable by day 10.
Choice B is wrong because a client who is 3 days postpartum and has not had a bowel movement since prior to admission is not uncommon.
Constipation is a common problem after delivery due to decreased peristalsis, dehydration, and fear of pain.
The nurse should encourage fluid intake, fiber intake, and early ambulation to promote bowel function.
Choice C is wrong because a client who is 4 days postpartum and has lochia serosa is also showing a normal finding.
Lochia serosa is the pinkish-brown discharge that occurs from day 4 to 10 after delivery.
It consists of old blood, serum, leukocytes, and tissue debris.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Justice is the ethical principle of treating the patient fairly and equally among staff when making assignments. The charge nurse is upholding this principle by ensuring that the workload is distributed evenly and that no staff member is overburdened or underutilized.
Choice A is wrong because Veracity is wrong because veracity is the ethical principle of telling the truth to the patient.
This principle is not relevant to the scenario of making assignments.
Choice C is wrong because Autonomy is wrong because autonomy is the ethical principle of respecting the patient’s right to make their own healthcare decisions.
This principle is not relevant to the scenario of making assignments.
Choice D is wrong because Fidelity is wrong because fidelity is the ethical principle of keeping promises to the patient.
This principle is not relevant to the scenario of making assignments.
Correct Answer is B
Explanation
Examine your testicles after a warm shower.
This is because a warm shower will relax the scrotum and the muscles holding the testicles, making an exam easier. You should gently roll the scrotum with your fingers to feel the surface of each testicle and check for any lumps, bumps, swelling, hardness or other changes.
Choice A is wrong because you should perform the self-examination every month, not every 3 months.
This will help you notice any changes over time.
Choice C is wrong because you should not palpate both testicles firmly with your fingertips. You should use a gentle touch and avoid squeezing or pressing too hard.
Choice D is wrong because you should not apply a cool compress to the scrotum prior to examination. This will make the scrotum contract and tighten, making an exam more difficult.
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