A client who gave birth vaginally with epidural anesthesia still has limited movement and strength of the right leg, and reports no urge to urinate at 2 hours postpartum. The nurse palpates the client's fundus 2 cm above the umbilicus and to the right. What should the nurse do next?

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11ecbb05_cc28_f7a4_b433_a9e7cd97a21a_MD0009_00 Postpartum urinary retention is commonly related to decreased bladder sensation (eg, due to regional anesthesia, prolonged labor, or perineal trauma) and postpartum diuresis. Urinary retention can cause bladder distension, which may be noted by a displaced and/or boggy uterus, or by a palpable bladder. If bladder distension cannot be resolved with spontaneous voiding, in-and-out (I&O) catheterization may be indicated, especially if the client: Is unable to ambulate to the restroom or void into a bedpan (Option C) Has not voided within 6-8 hours after delivery or removal of the indwelling urinary catheter after cesarean delivery Has difficulty emptying bladder completely (ie, voiding <100 mL frequently) (Option A) Postpartum clients are at risk for falls due to regional or general anesthesia, orthostatic hypotension, and changes in center of gravity. Risk of injury is increased in clients who ambulate before full sensory/motor function has returned. (Option B) Fluid intake may be encouraged postpartum but does not resolve the client's urinary retention and bladder distension. (Option D) A displaced fundus (ie, elevated above the umbilicus and/or to one side) is evidence of bladder distension. Reassessing in an hour may increase the risk of postpartum hemorrhage, as a full bladder can cause uterine atony. Educational objective: Signs of bladder distension in a postpartum client include a displaced and/or boggy uterus, or a palpable bladder. Performing an in-and-out catheterization can help prevent postpartum hemorrhage related to uterine atony and injuries related to falls if sensory/motor function of the lower extremities is decreased.

A Client Who Gave Birth Vaginally with Epidural Anesthesia Still