A nurse is assisting a client who had a cesarean delivery to get out of bed for the first time.

The nurse notices that the client’s incision site has opened and there is visible bowel protruding from the wound.

What is the appropriate action for the nurse to take?

Answer and explanation..

The correct answer is choice D. All of the above.Urinary retention is a common complication after cesarean delivery, and it can be detected by measuring the postvoid residual bladder volume (PVRBV) with an ultrasound scan.A PVRBV of more than 150 mL is considered abnormal and indicative of urinary retention.

The following findings should alert the nurse to this complication:

• Inability to void within 6 hours after delivery: This is a sign of overt urinary retention, which occurs in about 7.4% of women who had a cesarean delivery.It may be caused by factors such as pain, anxiety, anesthesia, or bladder trauma.

• Distended bladder palpable above the symphysis pubis: This is a sign of covert urinary retention, which occurs in about 16.7% of women who had a cesarean delivery.It means that the bladder is overfilled but the woman does not feel the urge to void or has difficulty initiating micturition.

• Urinary output of less than 30 mL per hour: This is a sign of inadequate bladder emptying, which may lead to urinary tract infection, bladder damage, or renal impairment.It may be due to factors such as morphine-related postoperative analgesia, multiple pregnancy, or low body mass index, which are associated with increased risk of urinary retention after cesarean delivery.

Normal ranges for PVRBV and urinary output are:

• PVRBV: less than 150 mL

• Urinary output: more than 30 mL per hour

The correct answer is choice A. Apply pressure to the bleeding site.This is because the client is showing signs of postpartum hemorrhage (PPH), which is severe vaginal bleeding after childbirth.PPH can occur up to 12 weeks postpartum, but it is more common within the first 24 hours.PPH can be caused by uterine atony, retained placenta, or trauma to the reproductive organs.

Applying pressure to the bleeding site can help to control the blood loss and prevent shock.

Choice B. Encourage early ambulation is wrong because it can worsen the bleeding and increase the risk of fainting.Early ambulation is beneficial for preventing thromboembolism and promoting recovery, but it should be done after the bleeding is stabilized.

Choice C. Apply sterile dressings to the incision is wrong because it does not address the source of bleeding, which is likely from the vagina or uterus.The incision site may also bleed, but it is usually less than the vaginal bleeding.

Applying sterile dressings to the incision can help to prevent infection, but it is not a priority intervention for PPH.

Choice D. Encourage frequent voiding is wrong because it can cause bladder distension and interfere with uterine contraction.A full bladder can displace the uterus and prevent it from compressing the blood vessels where the placenta was attached.

Encouraging frequent voiding can help to maintain bladder function and reduce discomfort, but it is not a priority intervention for PPH.

Normal ranges for heart rate are 60-100 beats per minute and for blood pressure are 90/60-120/80 mmHg.Normal blood loss after cesarean delivery is less than 1000 mL.