Question

The nurse has inserted a catheter 7.5 cm (3 inches) in a female patient and obtains no urine return even though her bladder is distended. What action should the nurse take at this time?

A. Remove the catheter and have another nurse attempt to catheterize the patient.

B. Leave the catheter in vagina as a landmark and insert another sterile catheter.

C. Remove the catheter and reinsert into the urethra. The nurse may straighten the urethra by inserting one finger of sterile gloved hand inside the vagina and applying gentle pressure upward.

D. Inflate the balloon and reassess in 1 hour for urine return in the bedside drainage bag.

Answer 1

The nurse should remove the catheter and reinsert it into the urethra using gentle pressure upward.

Step-by-step explanation:

The nurse should take action C: remove the catheter and reinsert into the urethra. The nurse can straighten the urethra by inserting one finger of a sterile gloved hand inside the vagina and applying gentle pressure upward. This can help to guide the catheter into the correct position. Inflating the balloon and reassessing for urine return in 1 hour is not recommended as there is no urine return despite a distended bladder, suggesting that the catheter is not in the correct position.

If a nurse inserts a catheter 7.5 cm into a female patient and obtains no urine return despite a distended bladder, the appropriate action would be option C: Remove the catheter and reinsert it into the urethra. The nurse may straighten the urethra by inserting one finger of a sterile gloved hand inside the vagina and applying gentle upward pressure. This step helps in guiding the catheter into the correct position to facilitate urine drainage from the bladder. It is important to note that if the catheter was initially inserted into the vagina by mistake, no urine would be obtained, and urine collection is essential for the patient's health to prevent complications such as urinary tract infections or bladder overdistention.