A 36-year-old patient who is gravida 5 para 5 (G5P5) was transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female.
She was in labor for 25 hours and forceps were used to assist with the delivery.
She was given an epidural for anesthesia that was effective.
The labor and delivery nurse reported that the patient had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale.
Her vital signs were stable.
Based on the assessment data, the nurse recognizes the need to intervene immediately.
Select the 5 priority interventions that the nurse should initiate based on the recent assessment.

.Administer a stool softener: This could be a good option to consider, as the client has not had a bowel movement since the surgery. However, the nurse should first consult with the healthcare provider before administering any new medications.

B.Ask the client about their normal bowel routine: This is a good action to take. Understanding the client’s normal bowel routine can provide valuable context for the current situation.

C.Hold the client’s next meal: This may not be necessary at this point. The client’s regular diet has been ordered by the provider, and there’s no indication of nausea, vomiting, or other symptoms that would necessitate holding meals.

D.Perform a digital rectal exam: This could be considered if there’s a concern about impaction or other complications. However, this should only be done after consulting with the healthcare provider.

E.Discontinue morphine: This is not advisable based on the information provided. The client is reporting uncontrolled pain, and morphine has been ordered by the provider for pain management. Any changes to pain medication should be discussed with the healthcare provider.

Choice A rationale

Phobia is characterized by an excessive and irrational fear response. In this case, the patient’s symptoms do not indicate a specific fear, but rather general distress and intrusive thoughts related to a traumatic event.

Choice B rationale

The patient’s symptoms, which include distressing thoughts and memories of the house collapsing, difficulty sleeping, and a significant change in mood, are indicative of acute stress disorder related to traumatic stress exposure. Acute stress disorder can occur within a month of experiencing a traumatic event, like a natural disaster.

Choice C rationale

Hallucinations involve perceiving something that is not present. The patient’s symptoms do not include any indications of hallucinations.

Choice D rationale

Separation anxiety involves excessive fear or anxiety about separation from those to whom the individual is attached. The patient’s symptoms do not indicate a fear of separation, but rather distress related to a traumatic event.