Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?
A. Fundus palpable to right of midline
A fundus palpable to the right of midline may indicate a distended bladder pushing the uterus to the side, and it requires intervention to promote bladder emptying.
B. Less than 2.5 cm of rubra lochia on perineal pad
Less than 2.5 cm of rubra lochia on a perineal pad is a normal finding in the early postpartum period.
C. Client report of increased thirst
Increased thirst is not directly indicative of bladder distention.
D. Client report of frequent uterine contractions
Frequent uterine contractions are expected in the postpartum period and do not necessarily indicate bladder distention.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Maternal Newborn Proctored Exam 3 Reno 2 2020. Take the full exam now
Full Explanation
A. A fundus palpable to the right of midline may indicate a distended bladder pushing the uterus to the side, and it requires intervention to promote bladder emptying.
B. Less than 2.5 cm of rubra lochia on a perineal pad is a normal finding in the early postpartum period.
C. Increased thirst is not directly indicative of bladder distention.
D. Frequent uterine contractions are expected in the postpartum period and do not necessarily indicate bladder distention.
Similar Questions
A newly delivered mother who intends to breastfeed tells her nurse, "I am so relieved that this pregnancy is over so that I can start smoking again." The nurse encourages the client to refrain from smoking. However, this new mother is insistent that she will resume smoking. How will the nurse adapt her health teaching with this new information?
A. The mother should always smoke in another room.
Encouraging the mother to smoke in another room helps reduce the exposure of the newborn to secondhand smoke.
B. The effects of secondhand smoke on infants are less significant than for adults.
The effects of secondhand smoke on infants are significant and can increase the risk of respiratory infections, sudden infant death syndrome (SIDS), and other health issues.
C. No relationship exists between smoking and the time of feedings.
There is a clear relationship between smoking and breastfeeding, and smoking during breastfeeding should be minimized.
D. Smoking has little-to-no effect on milk production.
Smoking can affect milk production and composition, and it is advisable for breastfeeding mothers to quit smoking.
Full Explanation
A. Encouraging the mother to smoke in another room helps reduce the exposure of the newborn to secondhand smoke.
B. The effects of secondhand smoke on infants are significant and can increase the risk of respiratory infections, sudden infant death syndrome (SIDS), and other health issues.
C. There is a clear relationship between smoking and breastfeeding, and smoking during breastfeeding should be minimized.
D. Smoking can affect milk production and composition, and it is advisable for breastfeeding mothers to quit smoking.
A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)
A. Blot the perineal area dry after cleansing.
Blotting the perineal area dry helps prevent moisture retention, reducing the risk of infection.
B. Perform hand hygiene before and after voiding.
Performing hand hygiene before and after voiding helps prevent the introduction of bacteria into the perineal area.
C. Apply ice packs to the perineal area several times daily.
Applying ice packs may help reduce swelling but is not a routine measure for preventing infection.
D. Clean the perineal area from front to back.
Cleaning the perineal area from front to back helps prevent the introduction of fecal bacteria into the urethra and vagina.
E. Wash the perineal area using a squeeze bottle of warm water after each voiding.
Washing the perineal area using a squeeze bottle of warm water after each voiding helps maintain cleanliness and prevent infection.
Full Explanation
A. Blotting the perineal area dry helps prevent moisture retention, reducing the risk of infection.
B. Performing hand hygiene before and after voiding helps prevent the introduction of bacteria into the perineal area.
C. Applying ice packs may help reduce swelling but is not a routine measure for preventing infection.
D. Cleaning the perineal area from front to back helps prevent the introduction of fecal bacteria into the urethra and vagina.
E. Washing the perineal area using a squeeze bottle of warm water after each voiding helps maintain cleanliness and prevent infection.
A nurse is caring for a client who experienced a vaginal delivery 16 hr ago. When palpating the client’s abdomen, at which of the following positions should the nurse expect to find the uterine fundus?
A. At the level of the umbilicus
The uterine fundus is expected to be at the level of the umbilicus after delivery and descends approximately one fingerbreadth (or 1 cm) per day after delivery.
B. 2 cm above the umbilicus
The uterine fundus would be too high for this time frame.
C. One fingerbreadth above the symphysis pubis
The fundus should reach the level of the symphysis pubis by 10 days postpartum.
D. To the right of the umbilicus
The uterine fundus should not be palpated to the right of the umbilicus; it should be midline or slightly to the right. A lateral displacement of the fundus may indicate a full bladder, which can interfere with uterine contraction and increase the risk of bleeding.
Full Explanation
A. The uterine fundus is expected to be at the level of the umbilicus after delivery and descends approximately one fingerbreadth (or 1 cm) per day after delivery.
B. The uterine fundus would be too high for this time frame.
C. The fundus should reach the level of the symphysis pubis by 10 days postpartum.
D. The uterine fundus should not be palpated to the right of the umbilicus; it should be midline or slightly to the right. A lateral displacement of the fundus may indicate a full bladder, which can interfere with uterine contraction and increase the risk of bleeding.