A nurse is caring for a client who is 1 hr postpartum.

Nurses' Notes 1200:

Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion.

1215:

Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.

Select the 6 actions the nurse should take.

Aspirate contents from the tube and verify the pH level.

• A. This is an incorrect action. Inserting air in the tube and listening for gurgling sounds in the epigastric area is not a reliable method to confirm NG tube placement, as it can produce falsepositive results due to air entering the stomach or intestines.
• B. This is a correct action. Aspirating contents from the tube and verifying the pH level is a valid method to confirm NG tube placement, as gastric contents typically have a pH of less than 5.5, while intestinal or respiratory contents have a higher pH.
• C. This is an incorrect action. Reviewing the medical record for previous x-ray verification of placement is not sufficient to confirm NG tube placement, as the tube can migrate or become dislodged after insertion. X-ray verification should be done initially and whenever there is doubt about the tube's position.
• D. This is an incorrect action. Auscultating the lungs for adventitious breath sounds is not a specific method to confirm NG tube placement, as it can indicate other conditions such as pneumonia or pulmonary edema. It can also miss signs of respiratory complications due to NG tube misplacement, such as pneumothorax or bronchial obstruction.

• A is incorrect because tinnitus, or ringing in the ears, is not an adverse effect of captopril, but rather a symptom of other conditions such as ear infection, noise exposure, or medication toxicity.
• B is correct because cough is a serious adverse effect of captopril, which is an angiotensinconverting enzyme (ACE) inhibitor that can cause angioedema, or swelling of the airways.
• C is incorrect because polyuria, or excessive urination, is not an adverse effect of captopril, but rather a symptom of other conditions such as diabetes mellitus, diabetes insipidus, or diuretic use.
• D is incorrect because blurred vision is not an adverse effect of captopril, but rather a symptom of other conditions such as eye strain, refractive error, or cataract.