[{"data":1,"prerenderedAt":64},["ShallowReactive",2],{"q-nurse-110-1-maternal-pediatric-025":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":32,"lastmod":63},"產兒科護理學","maternal-pediatric",{"id":7,"webId":8,"year":9,"session":10,"subject":4,"number":11,"stem":12,"options":13,"answer":18,"answerNote":19,"images":20,"explanation":21,"explanationDeep":22,"topics":23,"freq":10},"nurse-110-1-產兒科護理學-025","nurse-110-1-maternal-pediatric-025",110,1,25,"陳女士產後小便尚未自解，護理師評估結果為尿瀦留，下列敘述何者正確？",{"A":14,"B":15,"C":16,"D":17},"聽診下腹部有囉音","叩診恥骨聯合上方處有鼓音","陳女士目前為產後 3 小時","觸診腹部子宮底的位置偏向右側","D",null,[],"本題考點是產後尿瀦留（urinary retention）的評估表徵。考點在於膀胱脹尿會將子宮向上並向右側推移，故觸診時發現子宮底位置偏離中線、偏向右側，是尿瀦留的典型表徵，故D正確。A錯在囉音（rales）是肺部聽診的呼吸音，與膀胱評估無關，膀胱脹尿聽診並無囉音。B錯在膀胱脹滿時恥骨聯合上方叩診應呈濁音（dullness，因內含尿液），而非空腔的鼓音。C錯在產後3小時仍在正常應解尿時間範圍內，一般以產後6至8小時未解尿或殘尿過多才判定尿瀦留，單以3小時無法定義。理解「脹尿使子宮右移、叩診濁音」的定位表徵是解題核心。","產後尿瀦留常見於會陰水腫疼痛、產程長、器械生產或麻醉後膀胱張力恢復不佳。脹滿的膀胱在下腹形成可觸及的圓丘、叩診濁音，並把復舊中的子宮往上及往右頂，使子宮底偏離中線、收縮受阻，這正是尿瀦留最須警覺之處：子宮無法有效收縮易致產後出血。評估要點包括觸診子宮底高度與位置、叩診膀胱、記錄解尿時間與量、必要時測殘尿。處置先鼓勵自解（聽流水聲、溫水沖會陰、下床如廁），無效再導尿。子宮偏右＋叩診濁音是最經典的組合線索。",[24,26,28,30],{"term":25,"count":10},"產後尿瀦留",{"term":27,"count":10},"膀胱脹使子宮右移",{"term":29,"count":10},"膀胱叩診濁音",{"term":31,"count":10},"尿瀦留與產後出血",[33,37,42,47,52,57],{"webId":34,"stem":35,"number":36,"year":9,"session":10},"nurse-110-1-maternal-pediatric-026","承上題，此時護理師需優先注意的現象為何？",26,{"webId":38,"stem":39,"number":40,"year":9,"session":41},"nurse-110-2-maternal-pediatric-042","小強，5 歲，因溺水急救後送至急診，體溫為 29℃，下列處置何者錯誤？",42,2,{"webId":43,"stem":44,"number":45,"year":46,"session":10},"nurse-111-1-maternal-pediatric-056","依據娜姬（Nagy）的理論，9 歲兒童對死亡的概念為何？",56,111,{"webId":48,"stem":49,"number":50,"year":51,"session":41},"nurse-112-2-maternal-pediatric-014","王女士，懷孕 41 週，觀察其待產期間的胎心率變化。下列何種現象，需要特別處理？",14,112,{"webId":53,"stem":54,"number":55,"year":56,"session":41},"nurse-113-2-maternal-pediatric-038","為病童執行抽吸（suction）技術時，下列護理處置何者最適當？",38,113,{"webId":58,"stem":59,"number":60,"year":61,"session":62},"nurse-114-3-maternal-pediatric-032","小玲，2 歲，因骨折手術住院治療中，當您要進行換藥之疼痛評估時，下列何種疼痛評估工具最為適合？",32,114,3,"2026-09-04",1788510721809]