A nurse is caring for a client in active labor.

Exhibits

The nurse is assuming care for the client at 0305. For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.

A. “This medication can cause back pain.": Back pain is not a common or expected adverse effect of warfarin. If the client experiences unusual pain, especially accompanied by bruising or bleeding, it may warrant further evaluation but is not directly related to the medication itself.
B. "Avoid taking this medication with milk products.”: Warfarin does not interact with milk or dairy products in the way some antibiotics do. The more important dietary concern is maintaining consistent intake of vitamin K, found in green leafy vegetables.
C. “Take the last dose of the day 1 hour before bedtime.": Warfarin is typically taken once daily at the same time, but timing relative to bedtime is not critical. The key point is consistency and routine INR monitoring, not the hour of the day.
D. "Use an electric razor when shaving while taking this medication.": Warfarin increases bleeding risk, so using an electric razor helps minimize the chance of cuts and bleeding during shaving. This is a standard safety recommendation for clients on anticoagulants.

A. "The client was intubated without complications.": While relevant to the surgical process, this detail is more critical in the operating or PACU setting and less essential for ongoing post-op care unless complications occurred.
B. "The client is a member of the board of directors.": This is not clinically relevant and violates the client’s confidentiality by sharing unnecessary personal information.
C. "There was a total of 10 sponges used during the procedure.": Sponge count is important intraoperatively, but it is not typically necessary in a hand-off unless a count discrepancy occurred.
D. "The estimated blood loss was 250 milliliters.": This is clinically relevant and necessary for postoperative monitoring. It informs the receiving nurse about potential volume loss and the need to monitor for signs of hypovolemia.