Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Auscultate an area six inches below the umbilicus.

Palpate the area above the pubic symphysis.

Measure the girth of the client's lower abdomen.

Observe the appearance of the client's urine.

Answer and Explanation

The Correct Answer is B

A. Auscultating below the umbilicus is not effective for assessing urinary retention.

B. Palpating the area above the pubic symphysis allows the nurse to assess for bladder distention, which is a direct indicator of urinary retention.

C. Measuring the girth of the lower abdomen can be useful but is less specific than palpation for assessing bladder fullness.

D. Observing the urine's appearance does not directly assess for urinary retention.

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Correct Answer is C

Explanation

A. Decreasing expiratory pressure might not directly address the elevated PaCO2 and low pH.

B. Increasing tidal volume may help, but it’s more critical to address the ventilation rate first.

C. Increasing the rate of ventilation will help blow off more CO2, correcting the respiratory acidosis (elevated PaCO2 and low pH).

D. Decreasing expiratory flow time is less relevant than adjusting ventilation rates in this scenario.

A. client is 3 cm dilated, 40% effaced, and the fetal head is at -1 station B. contractions are occurring every 4 minutes and lasting 70 seconds C. fasting blood glucose (FSBG) is 86 (4.8 mmol/L) D. client dilates quickly to 10 cm and feels a strong urge to push E. fetal heart rate is reassuring with a baseline of 145 and moderate variability F. Apgar of 7 at 1 minute, then 9 at 5 minutes G. After three cycles of open-glottis pushing, the baby's head is crowning H. infant weighs 9 lbs. 9 oz I. membranes rupture at 38 weeks gestation

Correct Answer is ["A","B","C","D","E","F"]

Explanation

This blood glucose level is within the normal range, indicating that the client’s blood sugar is well-controlled at this point.

The client is 3 cm dilated, 40% effaced, with contractions every 4 minutes lasting 70 seconds and strong in quality. These are signs of active labor progressing appropriately.

The fetal heart rate is reassuring with a baseline of 145 beats per minute and moderate variability. This indicates good fetal well-being and adequate oxygenation.

The client quickly dilates to 10 cm and experiences a strong urge to push, suggesting efficient progress through labor.

The baby is born with an intact perineum, weighs 9 lbs. 9 oz (4.34 kg), and has excellent Apgar scores of 7 at 1 minute and 9 at 5 minutes. These scores indicate that the infant is in good condition and adapting well to extrauterine life.

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Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is ["A","B","C","D","E","F"]

Explanation

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

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