Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void every 2 hours?
Select one:

Frequent voiding encourages sphincter control.

A full bladder impedes oxygen ﬂow to the fetus.

Frequent voiding prevents bruising of the bladder.

A full bladder can impede fetal descent.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Frequent voiding encourages sphincter control. This is an incorrect statement that has no relevance to labor and delivery. Sphincter control refers to the ability to contract and relax the muscles that control urination and defecation. It is not aﬀected by frequent voiding.

Choice B Reason: A full bladder impedes oxygen ﬂow to the fetus. This is an incorrect statement that confuses a full bladder with a prolapsed cord. A prolapsed cord is a condition where the umbilical cord slips through the cervix before the baby and becomes compressed by the fetal head, which can reduce oxygen ﬂow to the fetus. A full bladder does not aﬀect oxygen ﬂow to the fetus.

Choice C Reason: Frequent voiding prevents bruising of the bladder. This is an incorrect statement that exaggerates the eﬀect of a full bladder on the bladder wall. A full bladder may cause some pressure or discomfort on the bladder, but it does not cause bruising or damage.

Choice D Reason: A full bladder can impede fetal descent. This is a correct statement that explains why it is important for the nurse to assess the bladder regularly and encourage the laboring client to void every 2 hours.

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Correct Answer is C

Explanation

Choice A Reason: Contact the physician, as it indicates early DIC. This is an incorrect answer that confuses a low pulse rate with a high pulse rate. DIC stands for disseminated intravascular coagulation, which is a life-threatening condition where abnormal clotting and bleeding occur simultaneously in the body. DIC can occur as a complication of postpartum hemorrhage, infection, or placental abruption. DIC can cause tachycardia (high pulse rate), not bradycardia (low pulse rate).

Choice B Reason: Contact the physician, as it is a first sign of postpartum eclampsia. This is an incorrect answer that misinterprets a low pulse rate as a sign of hypertension. Postpartum eclampsia is a condition where seizures occur in a woman who has preeclampsia or eclampsia after delivery. Preeclampsia and eclampsia are characterized by high blood pressure and proteinuria in pregnancy. Postpartum eclampsia can cause hypertension (high blood pressure), not hypotension (low blood pressure).

Choice C Reason: Document the finding as it is a normal finding at this time. This is because a pulse rate of 60 beats per minute is within the normal range for an adult and may reﬂect a physiological adaptation to the postpartum period. During pregnancy, the maternal blood volume and cardiac output increase, which can elevate the pulse rate. After delivery, these parameters gradually return to pre-pregnancy levels, which can lower the pulse rate.

Choice D Reason: Obtain an order for a CBC, as it suggests postpartum anemia. This is an incorrect answer that assumes that a low pulse rate is caused by anemia. Anemia is a condition where the red blood cell count or hemoglobin level is lower than normal, which can impair oxygen delivery to the tissues. Anemia can occur in the postpartum period due to blood loss during delivery or poor nutritional intake during pregnancy. Anemia can cause tachycardia (high pulse rate), not bradycardia (low pulse rate).

A. Daily weight. B. Consistency of stool. C. Volume of urine output. D. Blood pH.

Correct Answer is D

Explanation

Choice A Reason: Daily weight. This is an incorrect answer that indicates a valid parameter to assess hydration status. Daily weight is a measure of the body mass that can reﬂect changes in ﬂuid balance. Daily weight can help detect ﬂuid loss or gain in premature infants, who are more prone to dehydration or overhydration due to immature renal function and high insensible water loss.

Choice B Reason: Consistency of stool. This is an incorrect answer that indicates a valid parameter to assess hydration status. Consistency of stool is a measure of the texture and form of feces that can reﬂect changes in ﬂuid intake and absorption. Consistency of stool can help identify diarrhea or constipation in premature infants, who are more susceptible to gastrointestinal problems such as necrotizing enterocolitis or feeding intolerance.

Choice C Reason: Volume of urine output. This is an incorrect answer that indicates a valid parameter to assess hydration status. Volume of urine output is a measure of the amount of urine produced and excreted by the kidneys that can reﬂect changes in ﬂuid balance and renal function. Volume of urine output can help monitor hydration status and kidney function in premature infants, who are more vulnerable to ﬂuid overload or deficit and renal impairment.

Choice D Reason: Blood pH. This is because blood pH is a measure of the acidity or alkalinity of the blood, which reﬂects the balance between carbon dioxide and bicarbonate in the body. Blood pH is not a direct indicator of hydration status, which refers to the amount of water and electrolytes in the body. Hydration status can aﬀect blood pH, but blood pH can also be inﬂuenced by other factors such as respiratory or metabolic disorders.

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Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void every 2 hours? Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take? Select one:

Correct Answer is C

Explanation

In caring for the premature infant, the nurse must continually assess hydration status. Parameters to assess would include all of the following except: Select one:

Correct Answer is D

Explanation

On the first prenatal visit, the woman's cervix feels softened upon examination. The nurse records this finding as: Select one:

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The nurse's initial action when caring for an otherwise stable, full term infant with a slightly decreased temperature is to: Select one:

The nurse assesses a newborn at 36 weeks' gestation, and the following behaviors are noted: nasal ﬂaring, labored breathing, and excessive mucus. The nurse is most concerned about: Select one:

Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void every 2 hours?
Select one: