A nurse is caring for a 24-year-old female client in the post-operative unit following a horseback riding accident.

Exhibits

Which of the following assessment findings should the nurse attend to right away?

Choice A rationale

Advancing from clear liquids as tolerated is important for the patient’s nutritional intake and postoperative recovery. However, it is not the most urgent task upon admission from the PACU. The nurse must first address immediate needs such as infection prevention and monitoring vital signs before considering dietary advancements. This step can be implemented once the patient’s initial postoperative stability is confirmed.

Choice B rationale

Administering cefazolin 1 gram IV every 6 hours is critical for preventing postoperative infections, especially in patients with surgical wounds. Prophylactic antibiotics are essential in reducing the risk of surgical site infections, which can lead to severe complications. Timely administration of antibiotics helps maintain therapeutic levels in the bloodstream, providing effective coverage against potential pathogens and promoting a positive postoperative outcome.

Choice C rationale

Straight catheterization if unable to void is important for managing urinary retention and preventing bladder distention. However, this intervention should be based on the patient’s condition and the amount of time since the last voiding. It is not the most urgent action upon admission from the PACU unless the patient is exhibiting signs of significant discomfort or bladder distention. Monitoring the patient’s urinary output is important but should follow the administration of prophylactic antibiotics.

Choice D rationale

Completing a blood cell count (CBC) in the morning is important for assessing the patient’s overall health and detecting any potential complications such as anemia or infection. However, it is not the most urgent action upon admission from the PACU. The nurse should prioritize tasks that address immediate postoperative needs, such as administering antibiotics and monitoring vital signs, before scheduling routine blood tests.

Assisting with pushing efforts:

• Goal: Support Epidural Anesthesia for Mother
• Reason: Epidural anesthesia can diminish the mother's ability to feel the urge to push during labor. Assisting with pushing efforts helps ensure effective delivery and supports the mother's ability to participate actively in the birthing process.

Administering bolus fluids:

• Goal: Support Epidural Anesthesia for Mother
• Reason: Administering bolus fluids can help prevent hypotension, a common side effect of epidural anesthesia. Ensuring adequate fluid volume maintains blood pressure and supports overall maternal hemodynamic stability.

Monitoring blood pressure:

• Goal: Support Epidural Anesthesia for Mother and Fetus
• Reason: Continuous monitoring of blood pressure is essential to detect and manage hypotension, ensuring both maternal and fetal well-being. It helps maintain adequate blood flow to the uterus and placenta, optimizing fetal perfusion.

Administering IV fluids:

• Goal: Support Epidural Anesthesia for Mother
• Reason: Administering IV fluids helps maintain hydration and blood pressure, counteracting the potential hypotensive effects of epidural anesthesia. It supports the mother's hemodynamic stability during labor.

Side positioning:

• Goal: Support Epidural Anesthesia for Mother and Fetus
• Reason: Side positioning optimizes uteroplacental blood flow and reduces the risk of aortocaval compression by the gravid uterus. It ensures better fetal perfusion and maternal comfort while receiving epidural anesthesia.