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 B
Explanation
A. Irrigating the insertion site with sterile water is not a standard part of the procedure.
B. Rh-negative clients are at risk for isoimmunization if fetal blood mixes with maternal blood during the procedure. Rh(D) immune globulin should be administered after the procedure to prevent Rh sensitization.
C. The client is usually positioned supine with a slight tilt to prevent vena cava compression, not strictly in a left lateral position.
D. Amniocentesis does not require the client to be NPO.
Correct Answer is B
Explanation
A. Ondansetron is used to treat nausea but is not a routine pre-epidural intervention.
B. Administering an IV fluid bolus before epidural anesthesia helps prevent hypotension caused by sympathetic blockade.
C. Epidurals can be administered earlier than 7 cm dilation based on maternal request and clinical assessment.
D. Oxygen administration is not routinely required before an epidural unless fetal distress or maternal hypoxia is present.
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