A nurse is caring for a postpartum client with a distended bladder. The client is assisted to the bathroom, but is unable to void. Which of the following interventions would be contraindicated?
Use the bladder scanner to assess for urinary retention.
Catheterize to empty the bladder.
Place peppermint oil on a cotton ball and place it in the urinary “hat” while the client is on the toilet.
Assist the client back to bed and tell her to try to void again in 2 hours.
The Correct Answer is D
Choice A rationale
Using a bladder scanner to assess for urinary retention is a non-invasive and appropriate intervention. It helps determine the volume of urine in the bladder and can guide further management. This method avoids unnecessary catheterization and reduces the risk of infection.
Choice B rationale
Catheterizing to empty the bladder is a common intervention for urinary retention. However, it should be done with caution and only when necessary to avoid the risk of infection. In this scenario, it is not contraindicated but should be considered after other non-invasive methods have been tried.
Choice C rationale
Placing peppermint oil on a cotton ball and placing it in the urinary “hat” while the client is on the toilet is a non-invasive method that can help stimulate urination through the scent of peppermint. This method is safe and can be effective for some clients.
Choice D rationale
Assisting the client back to bed and telling her to try to void again in 2 hours is contraindicated because it delays the intervention for a distended bladder. A distended bladder can cause discomfort and potential complications, so timely intervention is necessary.
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Correct Answer is D
Explanation
Choice A rationale
The rubella vaccine should not be taken during pregnancy. It is a live attenuated vaccine, and there is a theoretical risk of harm to the developing fetus. Therefore, it is recommended to receive the vaccine before pregnancy.
Choice B rationale
The rubella vaccine is not recommended during each pregnancy. It is typically given as part of the MMR (measles, mumps, rubella) vaccine series in childhood, and immunity is usually lifelong. A booster dose is not needed during each pregnancy.
Choice C rationale
The rubella vaccine is not related to the Rh status of the baby. The vaccine is given to prevent rubella infection, which can cause serious birth defects if contracted during pregnancy.
Choice D rationale
The correct statement is that the client should avoid pregnancy for 28 days after receiving the rubella vaccine. This is to ensure that the live attenuated virus does not pose a risk to a developing fetus.
Correct Answer is A
Explanation
Choice A rationale
An intrauterine device (IUD) is one of the most reliable methods of contraception. It is a small, T-shaped device inserted into the uterus by a healthcare provider. IUDs can be hormonal or non-hormonal (copper). Hormonal IUDs release progestin, which thickens cervical mucus to prevent sperm from reaching the egg and thins the uterine lining to prevent implantation. Copper IUDs release copper ions, which are toxic to sperm. Both types of IUDs are over 99% effective and can last for several years, making them a highly reliable form of contraception.
Choice B rationale
Oral contraceptives, commonly known as birth control pills, are also effective but require daily adherence. They contain hormones (estrogen and progestin) that prevent ovulation, thicken cervical mucus, and thin the uterine lining. However, their effectiveness can decrease with missed doses, certain medications, or gastrointestinal disturbances. With typical use, their effectiveness is around 91%, meaning 9 out of 100 women may become pregnant each year.
Choice C rationale
Male condoms are a barrier method of contraception that prevent sperm from entering the uterus. They are also effective in preventing sexually transmitted infections (STIs). However, their effectiveness can be compromised by improper use, breakage, or slippage. With typical use, male condoms are about 85% effective, meaning 15 out of 100 women may become pregnant each year.
Choice D rationale
A diaphragm with spermicide is a barrier method of contraception. The diaphragm is a shallow, dome-shaped cup inserted into the vagina to cover the cervix, and spermicide is applied to kill sperm. Its effectiveness depends on correct and consistent use. With typical use, diaphragms are about 88% effective, meaning 12 out of 100 women may become pregnant each year. Additionally, diaphragms do not protect against STIs.