A postpartum client has been unable to void since her delivery of her

A postpartum client has been unable to void since her delivery of her baby this morning. Which of the following nursing measures would be beneficial for the client initially?

1. Increase fluid intake to 3500 mL.
2. Insert indwelling Foley catheter.
3. Rinse the perineum with warm water.
4. Apply firm pressure over the bladder.

ANSWER

ANS: 3
The nurse can pour warm water over the client’s perineum and create the sensation 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 for UTI, it should be avoided if possible. The nurse should try other noninvasive measures to promote urination before calling the health care provider 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 ex-erting force on the client’s uterus at this time.