The nurse decides to perform a prescribed PRN intermittent sterile catheterization on a postpartum client if which occurs? (Select all that apply.)
a. The client has not voided but the bladder cannot be palpated.
b. The fundus is displaced from the midline and the client has been unable to void.
c. The client has been medicated for pain but she has not voided; the fundus is midline.
d. The amount voided is less than 150 mL and the fundus is displaced from the midline.
ANS: B, D
The nurse makes the decision to perform an intermittent sterile catheterization if the client is unable to void, the amount is less than 150 mL, and the fundus is displaced. A nonpalpable bladder and firm fundus at or below the umbilicus and in the midline confirm that the bladder is empty and rule out urinary retention with overflow.
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