A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take?

The correct answer is choice c. Dry the newborn.

Choice A rationale:

Confirming identification and applying a bracelet is important for ensuring the newborn’s identity and preventing mix-ups, but it is not the immediate priority right after birth.

Choice B rationale:

Examining the newborn for birth defects is crucial for identifying any immediate health concerns, but it should be done after initial stabilization measures like drying and warming the newborn.

Choice C rationale:

Drying the newborn is the first action the nurse should take immediately after delivery. This helps to prevent heat loss and maintain the newborn’s body temperature, which is critical for their survival and well-being.

Choice D rationale:

Conducting a gestational age assessment is important for determining the newborn’s maturity and potential health risks, but it is not the immediate priority right after birth.

Choice A rationale :

Prepare for cesarean birth. The nurse should consider preparing for a cesarean birth as the client is at 39 weeks of gestation and has heavy vaginal bleeding. Heavy vaginal bleeding during pregnancy could indicate an emergency situation such as placental abruption or placenta previa, both of which can be life-threatening for the mother and the baby. In such cases, an emergency cesarean birth might be necessary to ensure the safety of both the client and the baby. Promptly preparing for the procedure will help expedite the process and prevent any delays in providing necessary medical care.

Choice B rationale

Initiate an IV infusion of magnesium sulfate. Magnesium sulfate is not indicated in this situation. Magnesium sulfate is commonly used in obstetrics, particularly in the management of preeclampsia and eclampsia to prevent seizures. However, the client's heavy vaginal bleeding suggests a different issue and magnesium sulfate would not address the underlying cause. Instead, the focus should be on identifying and managing the cause of the bleeding to ensure the best outcome for the client and the baby.

Choice C rationale

Administer antibiotics. Administering antibiotics is not the priority action in this scenario. Heavy vaginal bleeding in a pregnant client requires immediate attention to assess the cause and determine the appropriate course of action. While antibiotics may be necessary in some situations, they are not the first-line treatment for heavy vaginal bleeding during pregnancy. The nurse should focus on providing prompt and appropriate care to address the client's immediate needs.

Choice D rationale

Request the RN to perform a cervical examination. Performing a cervical examination may provide valuable information about the cause of the heavy vaginal bleeding. It can help determine if the bleeding is related to cervical changes, such as cervical dilation or effacement. The findings from the cervical examination, along with other assessments, will aid in making the most appropriate decisions regarding the client's care. However, it is not the only action that the nurse should take. In this critical situation, the nurse must prioritize immediate interventions to ensure the safety and well-being of the client and the baby.