A client who is multiparous at 38-weeks gestation is admitted to labor and delivery with contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the practical nurse (PN) hears a baby crying. Which action should the PN take first?

A. Bringing the client to sit at the nursing station may not address the underlying cause of the wandering behavior and could be less effective in meeting the client’s immediate needs.
B. Administering a nighttime sedative is not a suitable solution for wandering behavior, as it may lead to adverse effects and does not address the root cause of the behavior.
C. Directing the client to go back to bed may not be effective, especially if the client is disoriented or confused. The approach should involve understanding and addressing the client's needs.
D. Engaging the client to determine current needs is the best approach, as it helps to understand the cause of the wandering and address it appropriately, such as providing comfort, reassurance, or addressing a specific need.

A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up