A nurse is caring for a client who is postpartum and is having difficulty voiding. Which action should the nurse take first?

A nurse is caring for a client who is postpartum and is having difficulty voiding. Which action should the nurse take first?

• A. Assist the client to the bathroom.
• B. Notify the physician to schedule catheterization.
• C. Instruct the client to drink caffeinated beverages to stimulate voiding.
• D. Proceed with immediate catheterization without assessment.

Answer: (A)

The initial priority is to promote voiding with a noninvasive approach and assess bladder status. Assisting the postpartum client to the bathroom gives her the opportunity to void, which helps relieve bladder distention that can interfere with uterine involution and increase the risk of hemorrhage. It also allows the nurse to observe whether voiding occurs spontaneously and to note the amount voided. If the client can void after being assisted, then continue to monitor and encourage fluids as appropriate. If she still cannot void after attempting, the next steps involve noninvasive assessment (such as a bladder scan to check residual urine) and seeking orders for catheterization only if indicated. Jumping directly to catheterization or scheduling it without assessing bladder status is not appropriate, and giving caffeinated beverages is not a reliable or recommended intervention for this situation.

The initial priority is to promote voiding with a noninvasive approach and assess bladder status. Assisting the postpartum client to the bathroom gives her the opportunity to void, which helps relieve bladder distention that can interfere with uterine involution and increase the risk of hemorrhage. It also allows the nurse to observe whether voiding occurs spontaneously and to note the amount voided.

If the client can void after being assisted, then continue to monitor and encourage fluids as appropriate. If she still cannot void after attempting, the next steps involve noninvasive assessment (such as a bladder scan to check residual urine) and seeking orders for catheterization only if indicated. Jumping directly to catheterization or scheduling it without assessing bladder status is not appropriate, and giving caffeinated beverages is not a reliable or recommended intervention for this situation.