Which action is used to monitor bladder distention in Miranda Johnson's scenario?

Which action is used to monitor bladder distention in Miranda Johnson's scenario?

• A. Monitor bladder distention
• B. Alternate client positioning from side to side every hour
• C. Monitor temperature every 2 hours
• D. Administer rapid IV fluid of lactated Ringer's

Answer: (A)

Monitoring bladder distention directly assesses whether the bladder is full, indicating urinary retention. In Miranda Johnson's scenario, this is the essential step because detecting a distended bladder allows early intervention to prevent complications such as impaired uterine involution or discomfort. By regularly assessing for bladder fullness—through palpation or bladder scanning and noting urine output—you obtain the needed information to decide if further action, like catheterization or adjustments in care, is required. Other actions don’t address the immediate status of the bladder: alternating positioning helps comfort and circulation, not bladder assessment; checking temperature tracks for fever or infection rather than urinary retention; rapid IV fluids affect hydration and urine production but don’t monitor bladder status.

Monitoring bladder distention directly assesses whether the bladder is full, indicating urinary retention. In Miranda Johnson's scenario, this is the essential step because detecting a distended bladder allows early intervention to prevent complications such as impaired uterine involution or discomfort. By regularly assessing for bladder fullness—through palpation or bladder scanning and noting urine output—you obtain the needed information to decide if further action, like catheterization or adjustments in care, is required.

Other actions don’t address the immediate status of the bladder: alternating positioning helps comfort and circulation, not bladder assessment; checking temperature tracks for fever or infection rather than urinary retention; rapid IV fluids affect hydration and urine production but don’t monitor bladder status.