A nurse is caring for a client who had a vaginal birth 4 hr ago and had a 3rd-degree perineal laceration with repair. The client has been unable to void since giving birth. Which of the following findings indicates the need for straight catheterization?

The client rates perineal pain a 3 on a scale of 0 to 10.

The client's fundus is boggy and deviated to the right

The client has a moderate amount of lochia rubra

The client's perineum is ecchymotic with moderate edema

Answer and Explanation

The Correct Answer is B

A. A pain rating of 3 is relatively mild and does not indicate urinary retention.
B. A boggy, deviated fundus suggests bladder distention, which can occur when the bladder is full and displaces the uterus. This is an indication for straight catheterization to relieve urinary retention.
C. Moderate lochia rubra is expected 4 hours postpartum and does not indicate urinary retention.
D. While edema and bruising are common after delivery, they do not alone indicate a need for catheterization.

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Correct Answer is B

Explanation

A. Pale blue hands and feet (acrocyanosis) are normal during the first 24 hours after birth.
B. Soft grunting noises can indicate respiratory distress and should be reported promptly.
C. Blood-tinged vaginal discharge (pseudomenstruation) is normal in newborn females due to maternal hormones.
D. A positive Babinski reflex is a normal neurologic finding in newborns.

A. Breast enlargement B. Skin mottling C. Nipple inversion D. Thinning hair

Correct Answer is A

Explanation

A. Breast enlargement is a common and expected change during pregnancy due to hormonal influences.
B. Skin mottling is not a typical pregnancy change.
C. Nipples usually become more prominent or everted, not inverted, during pregnancy.
D. Hair tends to become thicker and fuller during pregnancy, not thinner.

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A nurse is caring for a client who had a vaginal birth 4 hr ago and had a 3rd-degree perineal laceration with repair. The client has been unable to void since giving birth. Which of the following findings indicates the need for straight catheterization?

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