A nurse is caring for a client who had a vaginal birth 4 hr ago and had a 3rd-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 a 3 on a scale of 0 to 10.
The client's fundus is boggy and deviated to the right
The client has a moderate amount of lochia rubra
The client's perineum is ecchymotic with moderate edema
The Correct Answer is B
A. A pain rating of 3 is relatively mild and does not indicate urinary retention.
B. A boggy, deviated fundus suggests bladder distention, which can occur when the bladder is full and displaces the uterus. This is an indication for straight catheterization to relieve urinary retention.
C. Moderate lochia rubra is expected 4 hours postpartum and does not indicate urinary retention.
D. While edema and bruising are common after delivery, they do not alone indicate a need for catheterization.
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Related Questions
Correct Answer is C
Explanation
A. It is normal for the newborn’s cord stump to remain attached for up to 1-2 weeks.
B. Newborns typically sleep 16-20 hours per day, so this is expected.
C. Fewer than four wet diapers in 24 hours can indicate inadequate hydration or feeding and requires immediate evaluation.
D. Loose stools are common in breastfed newborns and are generally not concerning.
Correct Answer is D
Explanation
A. Fetal fibronectin testing is used to assess risk for preterm labor, not to confirm rupture of membranes.
B. Amniocentesis for fetal lung maturity is generally not needed at 37 weeks or later.
C. Urinalysis is for urinary tract issues, not for detecting amniotic fluid.
D. Nitrazine testing helps determine if vaginal fluid is amniotic fluid by assessing pH, aiding in diagnosing rupture of membranes.
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