1. A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.

Exhibit 1

Nurses' Notes

0700:

Breasts soft, nipples intact. Uterus palpated firm, midline, and at level of umbilicus. Moderate amount of lochia rubra. Episiotomy site well approximated with mild edema and ecchymosis. Client reports pain as 2 on a scale of 0 to 10. Able to void spontaneously; no bladder distention. Deep tendon reflexes 1+. Peripheral edema 2+ in bilateral lower extremities.

1100:

Breasts soft, nipples intact. Uterus palpated soft with lateral deviation and 1 cm above the umbilicus. Large amount of lochia rubra. Episiotomy site well approximated with mild edema and ecchymosis. Client reports pain as 3 on a scale of 0 to 10. Deep tendon reflexes 1+ Peripheral edema 2+ in bilateral lower extremities.

Exhibit 2

0700:

Temperature 36.2" C (97.2" F) Pulse rate 80/min

Respiratory rate 16/min

Blood pressure 136/82 mm Hg

Pulse oximetry 99%

1100:

Temperature 37.2° C (99.0° F)

Pulse rate 85/min

Respiratory rate 18/min

Blood pressure 136/86 mm Hg

Pulse oximetry 100%

Select the 3 findings that require immediate follow-up.

Explanation:

A. Airborne precautions:

Airborne precautions are used for pathogens that are transmitted through the air over long distances. This includes pathogens such as Mycobacterium tuberculosis (TB) or varicella-zoster virus (chickenpox). However, Clostridium difficile (C. difficile) infection is not transmitted through the airborne route. Therefore, airborne precautions are not appropriate for managing C. difficile infection.

B. Droplet precautions:

Droplet precautions are used for pathogens that are transmitted through respiratory droplets, typically over short distances (usually within about 3 feet). This includes pathogens such as influenza virus or Bordetella pertussis (whooping cough). However, C. difficile infection is primarily transmitted through the fecal-oral route and contact with contaminated surfaces or objects, rather than through respiratory droplets. Therefore, droplet precautions are not appropriate for managing C. difficile infection.

C. Protective environment:

Protective environment, also known as reverse isolation, is used to protect immunocompromised clients from pathogens in the environment. This includes clients who have undergone bone marrow transplantation or chemotherapy. However, protective environment precautions are not appropriate for managing C. difficile infection. C. difficile infection control measures primarily focus on preventing the spread of the infection to others, rather than protecting the client from external pathogens.

D. Contact precautions:

Contact precautions are used for pathogens that are transmitted through direct or indirect contact with the client or their environment. This includes pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) or C. difficile. C. difficile infection is primarily transmitted through contact with contaminated surfaces or objects. Therefore, contact precautions, which involve measures to prevent the transmission of infectious agents via contact, including wearing gloves and a gown, performing hand hygiene, and ensuring environmental cleaning and disinfection, are appropriate for managing C. difficile infection.

A. Administer oxygen via face mask at 10 L/min:

Administering oxygen can help improve tissue oxygenation and prevent hypoxia, which is critical in managing a client at risk of hypovolemic shock. However, while oxygenation is important, it may not directly address the underlying cause of the excessive bleeding. Therefore, while oxygen may be necessary, it is not the most immediate action required to address the potential cause of the hemorrhage.

B. Collect hemoglobin and hematocrit levels:

Collecting hemoglobin and hematocrit levels is essential for assessing the extent of blood loss and the client's hemodynamic status. This information will help determine the severity of the situation and guide further management and interventions, such as blood transfusion if indicated. Since postpartum hemorrhage is a leading cause of maternal mortality, prompt assessment of blood loss is crucial in guiding appropriate interventions to prevent further complications.

C. Prepare the client to receive a plasma expander:

Plasma expanders may be administered to help restore circulating blood volume in cases of hypovolemic shock due to significant blood loss. However, before initiating plasma expander administration, it is essential to assess the client's hemoglobin and hematocrit levels to determine the severity of blood loss and guide appropriate fluid resuscitation strategies. Therefore, preparing the client to receive a plasma expander would come after assessing the extent of blood loss through laboratory values.

D. Insert an indwelling urinary catheter:

Inserting an indwelling urinary catheter may be necessary to monitor urinary output, which is an important indicator of renal perfusion and overall fluid status. However, while urinary catheterization is important for assessing renal function and fluid balance, it is not the most immediate action required to address the potential cause of the hemorrhage. Assessing blood loss through laboratory values and initiating appropriate interventions to manage postpartum hemorrhage take precedence over urinary catheterization in this scenario.