Urine output would be expected as this client has not voided for 6 hours (obligatory amount is at least 30 mL x 6 = 180 mL). The most common explanation is that the catheter was unintentionally inserted into the vagina. The nurse should leave that catheter as a landmark and insert a new sterile catheter into the urethra which is located above the vagina.
(Option 2) There sometimes can be a brief (15 second) delay from the water-based lubricant partially blocking the opening before quickly "melting." 30 minutes is too long a delay without an additional intervention. There is no reason to wait that long.
(Option 3) There is no sign that there is an obstruction; the catheter was not adequately inserted.
(Option 4) A urinary catheter should never be reused as it is no longer sterile and may introduce bacteria in the urinary tract, a new one should always be obtained. By removing the first catheter, the nurse will be more likely to re-insert it into the same (wrong) opening.
Educational objective: If no urine is returned from Foley catheter insertion in a female client after a short time, the nurse has probably not inserted it into the correct opening. The nurse should leave the original catheter in place and reinsert a new sterile catheter above the original position.
Urine output would be expected as this client has not voided for 6 hours (obligatory amount is at least 30 mL x 6 = 180 mL). The most common explanation is that the catheter was unintentionally inserted into the vagina. The nurse should leave that catheter as a landmark and insert a new sterile catheter into the urethra which is located above the vagina.
(Option 2) There sometimes can be a brief (15 second) delay from the water-based lubricant partially blocking the opening before quickly "melting." 30 minutes is too long a delay without an additional intervention. There is no reason to wait that long.
(Option 3) There is no sign that there is an obstruction; the catheter was not adequately inserted.
(Option 4) A urinary catheter should never be reused as it is no longer sterile and may introduce bacteria in the urinary tract, a new one should always be obtained. By removing the first catheter, the nurse will be more likely to re-insert it into the same (wrong) opening.
Educational objective: If no urine is returned from Foley catheter insertion in a female client after a short time, the nurse has probably not inserted it into the correct opening. The nurse should leave the original catheter in place and reinsert a new sterile catheter above the original position.
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