Question

A client with a history of uterine fibroids had a cesarean delivery 12 hours earlier and delivered healthy twins. At shift change, the nurse assesses the client and notes shortness of breath, cool extremities, and oozing of blood from the incision site. Based on the client's presentation, which nursing action has the highest priority?

A. Assess the client's temperature
B. Notify the healthcare provider
C. Clean the blood from the incision site
D. Draw labs for PT, PTT, CBC, and fibrinogen

Answer 1

The highest priority nursing action in this scenario is to notify the healthcare provider due to concerning symptoms such as shortness of breath and oozing of blood from the incision site.

Step-by-step explanation:

Based on the client's presentation, the nursing action that has the highest priority is B. Notify the healthcare provider. The client's symptoms of shortness of breath, cool extremities, and oozing of blood from the incision site are concerning and may indicate hemorrhage or other complications. Alerting the healthcare provider promptly will ensure that the client receives appropriate assessment and intervention to address these potentially serious issues.