Exhibits

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

Choice A rationale

Bladder distention upon palpation indicates urinary retention, meaning the client is unable to void effectively or empty the bladder completely. In the postpartum period, a full bladder can inhibit uterine contraction and increase the risk of postpartum hemorrhage because a distended bladder displaces the uterus, preventing it from clamping down appropriately. The normal range for post-void residual volume is typically less than 100 mL.

Choice B rationale

Not feeling the urge to urinate may be due to decreased bladder sensation following labor and delivery or effects of regional anesthesia, which can lead to urinary retention. Effective voiding is characterized by the ability to sense the urge to void, initiate urination, and empty the bladder, typically passing at least 150 mL per void after catheter removal.

Choice C rationale

Lateral displacement of the uterus is a common sign of a distended bladder. A full bladder pushes the uterus out of its normal midline position, impairing its ability to contract effectively, which increases the risk for uterine atony and subsequent postpartum hemorrhage. The fundus should remain firm and in the midline position after effective voiding.

Choice D rationale

The firming of the fundus with massage indicates that the uterus is contracting, which is essential for preventing postpartum hemorrhage by compressing the blood vessels at the placental site. Effective voiding allows the uterus to remain in its midline position, facilitating proper involution and contractility, which is reflected by a firm fundus.

Choice A rationale: Ceftriaxone IM is the recommended treatment for Neisseria gonorrhoeae infection during pregnancy. Untreated gonorrhea increases the risk of chorioamnionitis, preterm labor, premature rupture of membranes, and neonatal complications such as ophthalmia neonatorum. Ceftriaxone is safe in pregnancy and effective against gonorrhea. Prompt treatment prevents maternal complications and vertical transmission to the neonate. Therefore, administration of ceftriaxone IM is the correct nursing action in this case.

Choice B rationale: A blood culture is not indicated for a localized gonorrhea infection. Blood cultures are obtained when systemic infection or sepsis is suspected, which is not the case here. The client is asymptomatic aside from the positive culture result, with no fever, chills, or systemic signs of bacteremia. Therefore, obtaining a blood culture would not be an appropriate or necessary intervention in this scenario.

Choice C rationale: The rubella vaccine is a live attenuated vaccine and is contraindicated during pregnancy because of the potential teratogenic effects on the fetus. Women who are non-immune to rubella, as indicated by a titer less than 1:8, should be vaccinated postpartum before discharge to prevent infection in future pregnancies. Administering the vaccine during pregnancy is unsafe and therefore not an appropriate action at this time.

Choice D rationale: Maternal serum alpha-fetoprotein (MSAFP) screening is typically performed between 15 and 20 weeks of gestation to assess for neural tube defects and chromosomal abnormalities. At 12 weeks, it is too early to obtain this specimen, and the result would not be reliable. Therefore, ordering MSAFP at this gestational age is inappropriate. The correct timing should be discussed and scheduled for later in the pregnancy.