A nurse is caring for a client who had a vaginal birth 4 hours ago and had a third-degree perineal laceration with repair.
The client has been unable to void since giving birth. Which of the following findings indicates the need for straight catheterization?
The client rates perineal pain as 3 on a scale of 0 to 10.
The client has a moderate amount of lochia rubra.
The client's perineum is ecchymotic with moderate edema.
The client's fundus is boggy and deviated to the right.
The Correct Answer is D
Choice A rationale
A pain rating of 3/10 indicates mild pain and is a expected finding following a vaginal birth with a third-degree laceration repair. Pain alone is not the primary indicator for catheterization unless it is severe enough to prevent voiding. The focus for catheterization is on signs of urinary retention and its consequences, like uterine atony.
Choice B rationale
Lochia rubra (bright red discharge, typically lasting 1-3 days) is the expected type of lochia 4 hours postpartum, and a moderate amount is normal. The characteristics of lochia are indicators of uterine involution and healing, but do not directly confirm the need for a catheterization due to inability to void.
Choice C rationale
Ecchymosis (bruising) and edema of the perineum are expected signs following a vaginal birth, especially with a laceration and repair. While swelling can sometimes contribute to difficulty voiding, it is an expected localized finding and not the most direct indicator that immediate straight catheterization is required to manage urinary retention.
Choice D rationale
A boggy (soft, not contracted) and deviated uterus is the most critical sign indicating a full or distended bladder preventing the uterus from contracting effectively. This distention leads to urinary retention and significantly increases the client's risk for postpartum hemorrhage. Immediate straight catheterization is necessary to empty the bladder and allow the uterus to firm up.
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Correct Answer is B
Explanation
Choice A rationale
A speculum exam to test for fetal fibronectin is primarily used to predict the risk of preterm labor in symptomatic women between 22 and 34 weeks of gestation. Since the client is at 37 weeks of gestation (term) and the concern is a slow trickle of fluid suggesting rupture of membranes (ROM), this test is not appropriate for the current clinical presentation or gestational age.
Choice B rationale
Nitrazine testing is a rapid, non-invasive method used to determine if the fluid leaking from the vagina is amniotic fluid. Amniotic fluid is alkaline (pH of 7.0 to 7.5) and will turn the yellow-to-orange nitrazine paper to a characteristic deep blue color, which helps confirm the diagnosis of premature rupture of membranes (PROM), a likely cause of the reported fluid trickle.
Choice C rationale
A urinalysis determines components like protein, glucose, and ketones, and is mainly used to screen for conditions such as preeclampsia (indicated by proteinuria) or urinary tract infection (UTI). While part of routine prenatal care, it is not the diagnostic test for confirming ruptured membranes, which is the primary concern given the client's report of a slow trickle of vaginal fluid.
Choice D rationale
Amniocentesis is an invasive procedure used to aspirate amniotic fluid, typically to assess fetal lung maturity (L/S ratio) or for genetic testing. Since the client is at 37 weeks and the suspicion is ruptured membranes, which warrants immediate action due to infection risk, the risks and benefits of an amniocentesis for lung maturity are not justified.
Correct Answer is A
Explanation
Choice A rationale
Methylergonovine is an uterotonic agent that acts on the smooth muscle of the uterus to stimulate strong, sustained contractions, which are essential for compressing the intramyometrial blood vessels and achieving hemostasis to stop postpartum hemorrhage, especially from uterine atony.
Choice B rationale
While oxygen is important for hypoxia secondary to blood loss, administering it at 2 L/min via nasal cannula is typically insufficient for a client experiencing significant hemorrhage. High-flow oxygen, such as 10 to 15 L/min via nonrebreather mask, is usually required to maximize oxygen saturation.
Choice C rationale
Starting an IV bolus of Dextrose 5.
Choice D rationale
The knee-chest position is generally used to relieve cord compression or help with the manual rotation of the fetus, but it is not an established intervention for managing postpartum hemorrhage. The client should be positioned flat with legs elevated to promote venous return and manage shock.
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