Which assessment finding noted in a client 18 hours post vaginal delivery would indicate to the nurse that the client likely has a distended bladder?
a. Bright red blood noted on peripad
b. Height of fundus 3 fingerwidths above the umbilicus
c. Indwelling Foley catheter draining less than 30 mL urine per hour
d. Intermittent crampy pain midline in pelvis
B
The fundus should be one fingerbreadth below the umbilicus within 12 hours following birth. At 3 fingerbreadths, the nurse should suspect a distended bladder. The lochial drainage should be rubra (bright red bleeding) at this point. This is within normal limits. An indwelling Foley catheter draining less than 30 mL urine per hour would indicate possible dehydration or postpartal hemorrhage. The cramping is the normal characteristic of afterpains.
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