Following a cesarean section, a client's Foley catheter is discontinued at 2400 . She has not been able to void by 0600 and the fundus has risen from u/u to u+2 . What would be the correct nursing action?
a. After checking for a p.r.n. order, perform straight catheterization now.
b. Ask her to notify you as soon as she feels an urgency to void.
c. Ask if she has any bladder discomfort and medicate as ordered.
d. Force fluids if she is able to take liquids.
A
The bladder needs to be emptied, to avoid urinary strain and retention. An overfilled bladder will interfere with uterine involution. If she is unable to void and her bladder is so overfilled as to displace the uterus, it is doubtful the client will experience an urge to void. Medicating and forcing fluids will not address the problem of bladder distention.
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