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 ["A","D","E"]
Explanation
A. Labor induction with oxytocin increases the risk for uterine atony due to prolonged stimulation of uterine muscles, which predisposes the client to postpartum hemorrhage.
B. A newborn weight of 2.948 kg (6 lb 8 oz) is within normal range and does not increase the risk for postpartum hemorrhage.
C. A history of human papillomavirus (HPV) does not contribute to postpartum hemorrhage risk.
D. A history of uterine atony places the client at high risk for postpartum hemorrhage, as the uterus may fail to contract effectively after delivery.
E. Vacuum-assisted delivery increases the risk of trauma and retained placental fragments, both of which can lead to postpartum hemorrhage.
Correct Answer is D
Explanation
A. Water retention is not a common adverse effect of methylergonovine.
B. Tachycardia is not typically caused by methylergonovine; bradycardia or hypertension is more common.
C. Seizures are not a common side effect of this medication.
D. Hypertension is a known adverse effect of methylergonovine and requires close monitoring, especially in clients with preexisting hypertension.
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