A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?

Potential condition: Deep vein thrombosis

Based on the provided information, the client is most likely experiencing Deep Vein Thrombosis (DVT). This is suggested by the client's history of smoking, lack of exercise, obesity, recent surgery, and the fact that they are not wearing sequential compression devices due to discomfort.

Actions to Take

1. Request a prescription for a lower-extremity Doppler flow study: This will help confirm the presence of a blood clot in the deep veins.
2. Assess for Homan's sign: This is a clinical test used to check for DVT, although it's not always reliable.

Parameters to Monitor

1. Signs of bleeding after anticoagulation initiation: This is crucial because anticoagulants are often used to treat DVT, and monitoring for bleeding is essential.
2. PT/INR and platelet count: These parameters help assess the effectiveness and safety of anticoagulation therapy.

A. Assist the provider with inserting a fetal scalp electrode (FSE) and intrauterine pressure catheter (IUCP): This action is not the priority in the context of the client's current clinical status, particularly with the risk of placental abruption and severe bleeding. Fetal monitoring via scalp electrode and IUCP is typically reserved for stable clients, and invasive monitoring should be avoided in a potentially unstable situation.

B. Obtain serial H&H and clotting studies: The client is presenting with significant vaginal bleeding, low hemoglobin (8.1 g/dL at 0930, decreased to 7.5 g/dL at 1005), and low hematocrit levels (24% at 0930, dropping to 21% at 1005). Serial hemoglobin and hematocrit levels will help monitor ongoing blood loss and guide decisions regarding further interventions, such as transfusion. Clotting studies, including the prothrombin time and PTT, are necessary to assess the client's coagulation status and potential for disseminated intravascular coagulation (DIC), which can be associated with placental abruption or severe bleeding.

C. Administer misoprostol 600 mg rectally: Misoprostol is used to manage postpartum hemorrhage or to induce labor, but it is not indicated in the acute management of this client's condition. The client is 38 weeks gestation and presenting with signs of potential placental abruption, not requiring the use of misoprostol at this time.

D. Place the client in a supine position: The client should not be placed in a supine position, as this may exacerbate hypotension due to the supine hypotension syndrome, particularly if the uterus is compressing the inferior vena cava. The client would benefit more from positioning that promotes circulation, such as lying on the left side.

E. Prepare to transfuse 2 units of packed RBCs: The client is showing signs of hypovolemic shock with progressively declining blood pressure (from 95/62 mm Hg to 85/48 mm Hg), elevated heart rate (from 104/min to 128/min), and worsening hematocrit and hemoglobin. Blood transfusion is likely necessary to restore circulating volume, improve oxygen delivery, and address the ongoing blood loss.