Free NCLEX RN Practice Test Practice Question
The nurse is caring for a postpartum client 2 hours post-delivery who is unable to void. Which of the following nursing interventions should be considered initially?
Correct Answer: D
Rationale: The initial step in assessing a postpartum client unable to void is to palpate the bladder for distention and position (D). This intervention helps determine if urinary retention is present, guiding further actions.
Option A, inserting a straight catheter, might be necessary later but is not the first step; assessment is crucial before invasive procedures. Option B, encouraging oral fluid intake, is helpful but does not address the immediate concern of urinary retention. Option C, checking the perineum for swelling or hematoma, is important for overall assessment but does not directly assess bladder status.
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