A patient delivered 2 hours ago without medication. She is alert and active in bed but has not been out of bed yet. She states she needs to go the bathroom. What is the nurse's most appropriate response?
"I'll walk you to the bathroom and stay with you."
‘’I will get a bedpan for you."
‘’Leave your peri-pad in place after you use the restroom so I can check your bleeding when you get back."
‘’wait until I have had a chance to assess you first"
The Correct Answer is A
A) "I'll walk you to the bathroom and stay with you."
After delivery, the patient is at risk for orthostatic hypotension and falling, especially within the first few hours postpartum. Even though the patient feels alert and active, her body is still adjusting after childbirth, and she may be unsteady. The nurse should assist her to the bathroom and provide supervision for her safety. Walking the patient to the bathroom ensures she can safely get there while allowing the nurse to assess her mobility and vital signs if necessary.
B) "I will get a bedpan for you."
While a bedpan may be appropriate if the patient is unable to get out of bed, this response does not prioritize the patient's expressed desire to go to the bathroom. Since she is alert, active, and able to communicate, walking her to the bathroom is a safer and more appropriate option than offering a bedpan. Using a bedpan would also restrict her mobility unnecessarily.
C) "Leave your peri-pad in place after you use the restroom so I can check your bleeding when you get back."
This does not address the immediate concern of the patient’s safety in getting to the bathroom. The nurse's priority should be her safety and mobility right after delivery, especially as the patient is still recovering and may be at risk for fainting or falling.
D) "Wait until I have had a chance to assess you first."
While it is important to assess the patient’s physical state postpartum, the response here should focus on immediate safety rather than delaying her need to use the restroom. A full assessment can be conducted later, but it is not appropriate to restrict the patient's autonomy when she has already indicated the need to go to the bathroom.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Excessive uterine bleeding: A distended bladder can cause the uterus to become displaced to the right, preventing it from contracting effectively. This lack of uterine contraction can lead to uterine atony, which is a significant risk factor for excessive postpartum bleeding. When the uterus cannot contract well, it may result in continued
hemorrhage, which is a serious and immediate concern for postpartum patients.
B) A bladder rupture: While bladder rupture is a rare and severe complication, it is unlikely to occur in this situation. Bladder distention is a concern, but the most immediate danger is related to the uterus, not the bladder itself. A rupture would require significant trauma or extreme overdistention of the bladder, neither of which are described here.
C) Bladder wall atony: Bladder wall atony, where the bladder loses its ability to contract and expel urine, is not the most serious immediate consequence of bladder distention postpartum. While it may be uncomfortable and problematic, the main concern in this scenario is how bladder distention affects uterine contraction, which can lead to excessive bleeding.
D) Urinary tract infection: Although urinary retention can increase the risk of urinary tract infections (UTIs) due to incomplete bladder emptying, this is a less immediate and life-threatening concern compared to excessive bleeding. The primary concern in the immediate postpartum period is the potential for hemorrhage from uterine atony, which is worsened by bladder distention.
Correct Answer is A
Explanation
A) "Babies usually breathe in and out through their noses so they can feed without choking.":
Newborns are obligate nasal breathers, meaning they primarily breathe through their noses rather than their mouths, which helps coordinate breathing with feeding. This nasal breathing mechanism helps prevent aspiration and ensures that babies can feed while still breathing. It is perfectly normal for a baby to primarily use their nose for breathing, especially in the early days of life, and no cause for concern should be raised about small nasal openings unless the baby is showing signs of respiratory distress.
B) "You are right. I will report the baby's small nasal openings to the pediatrician right away.":
A small nasal opening is common in newborns and is not usually a cause for alarm unless it interferes with breathing, feeding, or shows signs of a more significant anatomical issue. There is no immediate need to report it unless the baby is having trouble breathing or feeding. The nurse should offer reassurance instead.
C) "Everything about babies is small. It truly is amazing how everything works so well.":
While this response may seem comforting, it is not very informative. It dismisses the mother’s concern rather than providing a clear and educational explanation. Reassuring the mother with factual information about why babies breathe through their noses and how this works effectively for them would be more helpful.
D) "The baby does rarely open his mouth but you can see that he isn't in any distress.":
This response minimizes the importance of the mother’s question and doesn’t fully address her concern. While it’s true that babies rarely open their mouths to breathe, the explanation needs to focus on the physiological reasoning behind it. The nurse should also reassure the mother that nasal breathing is normal in newborns and not typically a concern unless signs of distress are present.
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