A nurse is assisting with the care of a client who presents to the labor and delivery unit.

Exhibits

The nurse assisting with this client's care should expect which of the following prescriptions from the client's provider? Select all that apply.

Choice A rationale:

Administering an enema can help relieve the client’s abdominal cramping and small, hard, painful bowel movement. An enema is a procedure that involves introducing a liquid solution into the rectum to promote evacuation of feces. It can be used to relieve constipation, which seems to be the client’s issue based on the description of their bowel movement.

Choice B rationale:

Assisting the client with a sitz bath may not be necessary at this time. A sitz bath is typically used to soothe and cleanse the perineal area, particularly after childbirth or surgery. While the client does have a surgical incision, the notes indicate that the perineal dressing is intact with minimal serosanguinous drainage, suggesting that the incision site is not currently problematic.

Choice C rationale:

Irrigating an indwelling catheter with 500 mL of fluid is not recommended unless there is a specific indication, such as the catheter being blocked. The client’s urinary catheter is intact with 100 mL/hr of pink urine, which suggests that it is functioning properly.

Choice D rationale:

Encouraging prolonged dangling before ambulation may not be beneficial for this client. Dangling involves sitting on the edge of the bed with legs hanging down before standing up. This can help prevent dizziness upon standing. However, the notes indicate that the client is already ambulating independently in the hallway, suggesting that they do not have issues with mobility or dizziness.

Choice E rationale:

Encouraging oral fluid intake can help alleviate constipation by softening stools and promoting bowel movements. It can also help maintain hydration, which is particularly important for postoperative clients. Therefore, this would be a beneficial action for the nurse to take for this client.

Choice A rationale:

Stimulate the infant to cry. Stimulating the infant to cry is an important step in newborn care, as crying helps to clear the respiratory passages and establish effective breathing. However, it should not be the first action taken, as there are more immediate priorities in newborn care.

Choice B rationale:

Clear the respiratory tract. Clearing the respiratory tract should be the first action taken when caring for a newborn following a vaginal delivery. The newborn may have mucus or amniotic fluid in the airway, which can obstruct breathing. Clearing the airway ensures that the infant can breathe effectively. This action takes precedence over other tasks.

Choice C rationale:

Dry the infant off and cover the head. Drying the infant off and covering the head is important for maintaining the infant's temperature and preventing heat loss. However, it is not the first priority when compared to clearing the respiratory tract. Establishing effective breathing is of utmost importance.

Choice D rationale:

Clamp the umbilical cord. Clamping the umbilical cord is typically done after the baby is breathing and stable. It is an important step in the immediate post-delivery care, but it should not be the first action taken. Clearing the respiratory tract and ensuring the infant can breathe take precedence.