Question

A nurse is caring for a client who is 1 hr postpartum. What actions should the nurse take based on the provided information?

a) Assess for signs of infection

b) Administer oxytocin as ordered

c) Document the findings and continue monitoring

d) Notify the provider about the large clots and anxious feelings

Answer 1

Based on the provided information, the nurse should assess for signs of infection, document the findings and continue monitoring, and notify the provider about large clots and anxious feelings.

Step-by-step explanation:

Based on the provided information, the nurse should take the following actions:

1. Assess for signs of infection: The nurse should observe the client for any signs of infection, such as fever, foul-smelling vaginal discharge, or redness and swelling in the perineal area.
2. Document the findings and continue monitoring: The nurse should document the client's postpartum status and continue to monitor her closely, including monitoring vital signs and assessing for any complications.
3. Notify the provider about the large clots and anxious feelings: If the client is experiencing large clots and anxious feelings, which could be indicative of a possible postpartum hemorrhage or other complications, the nurse should promptly notify the provider for further evaluation and management.