A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?”. Which action should the practical nurse (PN) implement?

Catheterize the client for residual urine volume.

Evaluate for normal involution, then massage the fundus.

Measure the next voiding, then palpate the client's bladder.

Obtain a specimen for urine culture and sensitivity.

Answer and Explanation

The Correct Answer is C

Correct Answer: C. Measure the next voiding, then palpate the client's bladder.

Choice A rationale:

Catheterizing the client for residual urine volume is not necessary at this point because the woman has recently given birth, and frequent urination is common during the postpartum period. Additionally, catheterization poses risks of infection, so it should be reserved for situations where it is clinically indicated.

Choice B rationale:

Evaluating for normal involution and massaging the fundus is not relevant in this context. Fundal massage is performed after childbirth to ensure the uterus contracts and prevents excessive bleeding. The woman's concern is about frequent urination, which does not require fundal massage.

Choice C rationale:

Measuring the next voiding and palpating the client's bladder is the most appropriate action. The woman's increased frequency of urination could be due to postpartum diuresis, a normal physiological process where the body eliminates excess fluid accumulated during pregnancy. By measuring the next voiding and palpating the bladder, the nurse can assess for bladder distension or retention, which could be signs of a problem.

Choice D rationale:

Obtaining a specimen for urine culture and sensitivity is not indicated in this situation. There is no evidence to suggest that the woman has a urinary tract infection or other urinary issues that would warrant a urine culture at this time.

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Correct Answer is C

Explanation

The correct answer is C. Oriented to person only.

Choice A rationale:

A blood pressure of 144/84 mmHg is slightly elevated but not critically high. While it is important to monitor, it does not immediately impact the instructions for morning care.

Choice B rationale:

An oxygen saturation measurement of 95 to 96% is within the normal range and indicates adequate oxygenation. This is important to monitor but does not require specific changes to morning care instructions.

Choice C rationale:

Being oriented to person only indicates a significant alteration in the client’s cognitive status, which is crucial for the UAP to be aware of. This affects the client’s ability to understand and follow instructions, and may require additional supervision and safety measures during care.

Choice D rationale:

A urinary output of 50 mL/hour is within the normal range (typically 30-50 mL/hour is considered adequate). While it is important to monitor, it does not necessitate immediate changes to morning care instructions.

: 1

A. Include "Noncompliance”. as a priority problem in the client's plan of care. B. Advise the UAP to re-attempt the daily weight after the client eats breakfast. C. Consult with the client about the reasons for his refusal to be weighed D. Calculate the client's weight based on the 24-hour fluid intake and output.

Correct Answer is C

Explanation

The correct answer is choice C. Consult with the client about the reasons for his refusal to be weighed.

Choice A rationale:

Including "Noncompliance”. as a priority problem in the client's plan of care assumes the client's refusal to be weighed is intentional and willfully disobedient. This may not be the case, and labeling the client as noncompliant could create a negative atmosphere, hindering effective communication and care.

Choice B rationale:

Advising the UAP to re-attempt the daily weight after the client eats breakfast does not address the underlying reason for the client's refusal. Additionally, there is no evidence suggesting that weighing the client after breakfast will improve the situation.

Choice C rationale:

Consulting with the client about the reasons for his refusal to be weighed is the most appropriate action. Open communication with the client can help identify any concerns or fears related to the weighing process. By understanding the client's perspective, the healthcare team can work together to find a solution that ensures the client's cooperation with the weight monitoring.

Choice D rationale:

Calculating the client's weight based on the 24-hour fluid intake and output is not a reliable method for obtaining an accurate weight measurement. Fluid volume overload can lead to fluid retention and may not accurately reflect the client's true weight.

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A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?”. Which action should the practical nurse (PN) implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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