Fairly easy

A woman reports difficulty passing urine six hours after birth. Which action is most appropriate initially?

Correct answer: A. Assess bladder distension and encourage voiding

  • A. Assess bladder distension and encourage voiding
  • B. Restrict fluids until bladder control returns
  • C. Insert an indwelling catheter immediately
  • D. Tell her that urinary retention is expected

Explanation

The nurse should first assess for bladder distension and promote privacy, mobility and normal voiding. Untreated retention can displace the uterus and increase bleeding, but catheterisation is not automatically the first step.

Submitted by a TestUstad contributor and published by the TestUstad editorial teamLast updated
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Maternal postnatal care assesses uterine involution, lochia, perineal healing, bladder and bowel function, vital signs, emotional wellbeing and signs of puerperal infection or haemorrhage. Breastfeeding covers colostrum, milk production, positioning and attachment, feeding frequency, common difficulties and the distinction between normal breast changes and mastitis.

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