Exhibits

The nurse is assessing the client 15 minutes later. How should the nurse interpret the following findings?

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.

Choice A rationale

A transvaginal fetal Doppler probe is an internal device used early in pregnancy to confirm fetal viability or heart rate in the first trimester, not an appropriate method for continuous intrapartum monitoring in a full-term client with intact membranes.

Choice B rationale

The DeLee-Hillis fetoscope is an external acoustic device used for intermittent auscultation of the fetal heart rate, providing a listening assessment rather than the prescribed continuous electronic tracing required for this client.

Choice C rationale

An external ultrasound transducer monitor (or tocodynamometer for contractions) uses non-invasive Doppler technology placed on the client's abdomen to detect and continuously monitor the fetal heart rate and uterine contractions when membranes are intact, satisfying the continuous monitoring prescription without internal access.

Choice D rationale

An internal fetal scalp electrode (FSE) requires the rupture of membranes and sufficient cervical dilation for placement onto the fetal scalp to provide a precise electrocardiogram of the fetal heart, which is not applicable since the client's membranes are intact.