During insertion of a Foley catheter, the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse?
a. Withdraw the catheter
b. Ask the patient to bear down
c. Continue to inflate the balloon
d. Advance the catheter into the bladder
ANS: D
Grimacing is a sign of pain indicating that the balloon might be in the urethra instead of the bladder. The catheter should be advanced before inflation.
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