The nurse is assessing the urinary output of a patient 4 hours after a caesarean birth. The patient weighs 68 kg and the indwelling catheter bag measures 125 mL of urine. Which action will the nurse include in the plan of care?

Discontinue the indwelling catheter.

Increase intravenous fluid rate.

Check the catheter for patency.

Document the finding.

Answer and Explanation

The Correct Answer is C

Choice A reason: Discontinuing the indwelling catheter is not appropriate without first assessing the cause of the low urine output.

Choice B reason: Increasing the intravenous fluid rate might be considered if the patient is dehydrated, but first, the nurse should ensure that the low urine output is not due to a mechanical issue with the catheter.

Choice C reason: Checking the catheter for patency is the most immediate and appropriate action. There could be a blockage or kink in the catheter, which might explain the low urine output.

Choice D reason: Documenting the finding is important, but it should be done after addressing the immediate concern of low urine output and confirming that the catheter is functioning properly.

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Correct Answer is B

Explanation

Choice A reason: Difficulty sleeping and extreme fatigue are common postpartum symptoms, but they do not indicate an immediate emergency. This patient can be seen after addressing more urgent concerns.

Choice B reason: A patient who believes someone is going to steal their baby may be experiencing postpartum psychosis or severe anxiety. This is a serious mental health concern that requires immediate attention from a healthcare provider to ensure the safety and well-being of both the patient and the baby.

Choice C reason: Having a baby in the neonatal intensive care unit is certainly stressful and requires support, but it does not indicate an immediate medical emergency for the postpartum patient themselves. This patient can be seen after more urgent cases are addressed.

Choice D reason: A teenager who is 6 weeks postpartum with the flu requires medical care, but the symptoms of the flu are generally not as urgent as the mental health concerns presented by a patient experiencing severe anxiety or psychosis. This patient can be seen after more critical cases are attended to.

A. Vaginal delivery after 12 hours of Labor B. Primiparity delivered at 10 cm dilation C. Manual extraction of the placenta

Correct Answer is C

Explanation

Choice A reason: Vaginal delivery after 12 hours of Labor, while potentially exhausting for the mother, does not inherently place her at a higher risk for postpartum haemorrhage compared to other factors. Prolonged Labor can be associated with certain complications, but it is not the most direct indicator of increased haemorrhage risk in the postpartum period.

Choice B reason: Primiparity, or being a first-time mother, delivered at full dilation of 10 cm is a normal part of the childbirth process. While first-time mothers might experience longer Labor durations, this alone does not signify a higher risk for postpartum haemorrhage. Risk factors for haemorrhage typically involve conditions or interventions that impact the uterus's ability to contract effectively after birth.

Choice C reason: Manual extraction of the placenta is a significant risk factor for postpartum haemorrhage. When the placenta does not detach and deliver on its own, manual removal is necessary, which can cause trauma to the uterus and interfere with its ability to contract properly after delivery. The lack of effective uterine contraction can lead to increased bleeding, making this a higher risk scenario for postpartum haemorrhage.

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The nurse is assessing the urinary output of a patient 4 hours after a caesarean birth. The patient weighs 68 kg and the indwelling catheter bag measures 125 mL of urine. Which action will the nurse include in the plan of care?

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