Answer and explanation..

The correct answer is choice D. All of the above. Urinary retention is a common complication after cesarean delivery, and it can be detected by measuring the postvoid residual bladder volume (PVRBV) with an ultrasound scan. A PVRBV of more than 150 mL is considered abnormal and indicative of urinary retention.

The following findings should alert the nurse to this complication:

• Inability to void within 6 hours after delivery: This is a sign of overt urinary retention, which occurs in about 7.4% of women who had a cesarean delivery. It may be caused by factors such as pain, anxiety, anesthesia, or bladder trauma.

• Distended bladder palpable above the symphysis pubis: This is a sign of covert urinary retention, which occurs in about 16.7% of women who had a cesarean delivery. It means that the bladder is overfilled but the woman does not feel the urge to void or has difficulty initiating micturition.

• Urinary output of less than 30 mL per hour: This is a sign of inadequate bladder emptying, which may lead to urinary tract infection, bladder damage, or renal impairment. It may be due to factors such as morphine-related postoperative analgesia, multiple pregnancy, or low body mass index, which are associated with increased risk of urinary retention after cesarean delivery.

Normal ranges for PVRBV and urinary output are:

• PVRBV: less than 150 mL

• Urinary output: more than 30 mL per hour