A nurse is assisting with the care of a client who is experiencing a postpartum hemorrhage. Which of the following actions should the nurse take? (Select all that apply.).

Choice D reason: The nurse should report the laboratory result of 2+ proteinuria (Choice D) to the healthcare provider. Proteinuria is the presence of excess protein in the urine, which can indicate a potential kidney problem or a complication related to pregnancy, such as preeclampsia. Preeclampsia is a serious condition characterized by high blood pressure and damage to organs like the liver and kidneys. Therefore, this result needs immediate attention to assess the client's condition properly and take appropriate actions to ensure the safety and well-being of both the mother and the baby.

Choice A reason:

The 2-hour postprandial glucose level of 105 mg/dL (Choice A) is within the normal range. During pregnancy, glucose levels are carefully monitored to check for gestational diabetes. In this case, the result falls within the acceptable range, indicating that the client's glucose levels are stable, and gestational diabetes is not a concern at this time.

Choice B reason:

A negative group B streptococcus (GBS) B-hemolytic result (Choice B) is actually a positive finding. It means that the client does not have an active infection with group B streptococcus, which is essential information for the management of labor and delivery. Therefore, there is no need to report this result to the provider as it indicates a favorable condition.

Choice C reason:

The hemoglobin (Hgb) level of 13 g/dL (Choice C) is within the normal range for a non- pregnant adult female. During pregnancy, blood volume increases, and hemoglobin levels can naturally decrease. However, the provided value is still within the acceptable range, indicating that the client's blood oxygen-carrying capacity is adequate and there is no immediate concern.

Choice B reason: The nurse should ask the client if they have had thoughts about harming their infant. This is a crucial action because the client's statement suggests they may be experiencing feelings of inadequacy and self-doubt as a mother, which could potentially lead to more serious thoughts or actions. By directly asking about thoughts of harming the baby, the nurse can assess the client's mental and emotional state more thoroughly and determine if there is a risk of harm to the infant.

Choice A reason:

The nurse should advise the client that most new mothers experience these feelings. This response acknowledges the client's feelings of inadequacy and normalizes their experience, letting them know that it is common for new mothers to have doubts and insecurities. This validation can help the client feel less alone and more understood, promoting a therapeutic nurse-client relationship.

Choice C reason:

The nurse should explain to the client that they are experiencing the "baby blues.” This is a valid option because the client's statement indicates they may be experiencing mood swings, sadness, and emotional sensitivity, which are typical symptoms of the baby blues. Providing this information can help the client understand that these feelings are transient and often related to hormonal changes after childbirth.

Choice D reason:

Taking the client to the emergency department is not warranted based solely on the information provided. The client's statement does not indicate an immediate danger to themselves or their baby. However, if during the assessment (including choice B), the nurse identifies any signs of potential harm to the infant or the client, further action may be necessary, such as involving appropriate mental health professionals or support services.