A nurse is caring for a 59-year-old male client in the intermediate care unit.

Exhibits

Which of the following findings requires the nurse's immediate attention?

Choice A rationale: Fetal decelerations require immediate action because they indicate potential fetal distress. Continuous fetal monitoring is essential to assess the fetus's well-being, and any signs of distress must be addressed promptly to ensure a safe delivery.

Choice E rationale: Hypotension is a common side effect of epidural anesthesia and can lead to decreased blood flow to the fetus. Immediate intervention, such as administering IV fluids or medications, is necessary to stabilize the mother's blood pressure and ensure adequate fetal perfusion.

Choice F rationale: Difficulty breathing is a critical sign that may indicate a severe reaction to the epidural anesthesia or other complications. Immediate assessment and intervention are required to ensure the mother's respiratory status is stable and to address any underlying issues.

Choice B rationale: Reports of pain, while important, do not require immediate emergency action compared to the other findings. Pain management should be adjusted accordingly, but it does not pose an immediate threat to the mother or fetus.

Choice C rationale: Nausea, while uncomfortable, is a common side effect of epidural anesthesia and does not require immediate emergency intervention. It can be managed with antiemetic medications.

Choice D rationale: Dizziness can be a side effect of epidural anesthesia or hypotension, but it is not as critical as the other findings that require immediate emergency attention. It should be monitored and addressed as part of overall care.

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.