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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Discussing the suspicion of physical abuse with the provider isis essential, but it should not replace reporting to CPS. The provider’s input is valuable, but immediate action is necessary.
B. Confronting the parents with the suspicion of physical abuse is not an appropriate action for the nurse to take, as it can escalate the situation and endanger the child or the nurse.
C. Asking the hospital security to detain and question the parents is not an appropriate action for the nurse to take, as it violates the parents' rights and may interfere with the legal process.
D. Contacting Child Protective Servicesnurses are legally required to report all cases of suspected child abuse to the appropriate local or state agency.It's a critical step in protecting the child from further harm.
Correct Answer is B
Explanation
A. Incorrect. Maintaining a flexible daily schedule for the child may increase their anxiety and confusion, as they may have difficulty adapting to changes in routine and expectations. The nurse should advise the parents to establish a consistent and structured schedule for the child, with clear rules and boundaries.
B. Correct. Using a reward system to modify the child's behavior is an effective strategy to reinforce positive behaviors and reduce negative ones. The nurse should help the parents identify specific and measurable goals for the child, and provide them with praise, tokens, or privileges when they achieve them.
C. Incorrect. Providing a variety of family members to care for the child may overwhelm them and impair their social skills development, as they may have difficulty forming attachments and communicating with different people. The nurse should encourage the parents to select one or two primary caregivers for the child, who can provide them with consistent and supportive interactions.
D. Incorrect. Administering alprazolam as needed to reduce the child's anxiety is not recommended, as it may cause adverse effects such as sedation, dependence, or withdrawal symptoms. The nurse should educate the parents about nonpharmacological interventions for anxiety, such as relaxation techniques, cognitive behavioral therapy, or social skills training.
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