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

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

Evaluate for normal involution, then massage the fundus

Obtain a specimen for urine culture and sensitivity

Answer and Explanation

The Correct Answer is B

Urinary output is an important indicator of ﬂuid balance and kidney function. After delivery, a woman may experience increased urinary output due to the loss of excess ﬂuid that was retained during pregnancy and the diuretic eﬀect of oxytocin, which is released during breastfeeding. This is a normal and expected finding in the postpartum period.
However, increased urinary output may also be a sign of urinary retention, which is the inability to empty the bladder completely. Urinary retention can occur due to trauma to the bladder or urethra during delivery, swelling or hematoma of the perineum, epidural anesthesia, or decreased bladder sensation.Urinary retention can lead to complications such as infection, bladder distension, or postpartum hemorrhage.
Therefore, when a woman who delivered a normal newborn 24 hours ago reports that she seems to be urinating every hour or so, the practical nurse (PN) should measure the next voiding, then palpate the client's bladder. This will help to assess the amount and quality of urine and the presence or absence of bladder distension. A normal urine output is about 30 ml per hour, and a normal bladder should feel soft and empty after voiding. If the urine output is low or high, or if the bladder feels firm or full after voiding, the PN should report these findings to the primary healthcare provider for further evaluation and intervention.

Therefore, option B is the correct answer, while options A, C, and D are incorrect.

Option A is incorrect because catheterizing the client for residual urine volume is an invasive procedure that should only be done if indicated by the primary healthcare provider.

Option C is incorrect because evaluating for normal involution and massaging the fundus are related to uterine function, not urinary function.

Option D is incorrect because obtaining a specimen for urine culture and sensitivity is not necessary unless there are signs of infection, such as fever, dysuria, or foul-smelling urine.

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Correct Answer is A

Explanation

A. This is correct because discomfort while walking can indicate genital trauma or infection, which are possible signs of sexual abuse.
B. This is incorrect because thin extremities can be caused by many factors, such as malnutrition, genetic disorders, or chronic diseases, that are not necessarily related to sexual abuse.
C. This is incorrect because bruises on the upper back can result from accidental injuries, such as falls or bumps, or from physical abuse, such as hitting or kicking, but not specifically from sexual abuse.
D. This is incorrect because a stained shirt can be due to poor hygiene, food spills, or environmental factors, but not necessarily from sexual abuse.

A. Delegate non-nursing tasks to ancillary staff. B. Stock client rooms with extra supplies. C. Assign dedicated equipment to each client's room. D. Change continuous IV infusion tubing every 24 hr.

Correct Answer is A

Explanation

A is correct because delegating non-nursing tasks to ancillary staff allows nurses to focus on more complex and skilled tasks that require their expertise and judgment, thus improving efficiency and quality of care.

B is incorrect because stocking client rooms with extra supplies increases waste and costs, as well as clutter and infection risk.

C is incorrect because assigning dedicated equipment to each client's room reduces availability and accessibility of equipment for other clients, as well as increases maintenance and cleaning costs.

D is incorrect because changing continuous IV infusion tubing every 24 hr is not cost-effective, as it does not reduce the risk of infection significantly compared to changing it every 72 hr, according to current evidence-based practice guidelines.

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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?

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