Question

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take?

1. Provide oral fluids and begin fundal massage.
2. Begin hourly pad counts and reassure the client.
3. Elevate the head of the bed and assess vital signs.
4. Assess for hypovolemia and notify the health care provider (HCP).

Answer 1

The nurse should take immediate action by assessing for hypovolemia and notifying the health care provider (HCP).

Step-by-step explanation:

The nurse should take immediate action by option 4: Assess for hypovolemia and notify the health care provider (HCP). The client's cool, clammy skin, excessive thirst, and restlessness are signs of hypovolemia, which is a condition characterized by low blood volume.

This assessment finding suggests that the client may be experiencing postpartum hemorrhage, which is a serious complication after childbirth. The nurse should assess for any signs of bleeding, such as excessive vaginal bleeding, and notify the health care provider immediately for further evaluation and treatment.

The other options are not appropriate for the client's condition. Option 1 suggests providing oral fluids and beginning fundal massage, which may not address the underlying cause of the client's symptoms. Option 2 suggests beginning hourly pad counts and reassuring the client, which does not address the immediate need to assess for hypovolemia. Option 3 suggests elevating the head of the bed and assessing vital signs, which does not address the client's symptoms of cool, clammy skin and excessive thirst.