A postpartum client has been unable to void since her delivery of a baby this morning. Which of the following nursing measures would be beneficial for the client initially?
a. Increase the client's fluid intake to 3500 mL.
b. Insert indwelling Foley catheter.
c. Pour warm water over the client's perineum.
d. Apply firm pressure over the client's bladder.
C
The nurse can pour warm water over the client's perineum and create the urge to urinate.
A client with normal renal function who does not have heart or kidney disease should drink 2000 to 2500 mL of fluid daily. Increasing the client's fluid intake to 3500 mL is excessive.
Because bladder catheterization carries the risk of UTI, it should be avoided if possible. The nurse should try other noninvasive measures to promote urination before calling the physician for an order to insert a Foley catheter.
The nurse should not apply firm pressure over the bladder of a postpartum woman with an intact nervous system. The nurse could create more damage by exerting force on the client's uterus at this time.
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