A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury.

Exhibits

Select 1 condition and 1 client finding to fill in each blank in the following sentence.</p>

The client is at risk for developing

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due to

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.

A: Correct. Firmly massaging the uterine fundus helps to contract the uterus and reduce bleeding.

B: Correct. Providing emotional support helps to calm the client and reduce anxiety, which can worsen bleeding.

C: Correct. Administering oxygen helps to improve tissue perfusion and oxygenation, which can be compromised by blood loss.

D: Correct. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage.

E: Correct. Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively.

F: Correct. Administering methylergonovine helps to stimulate uterine contractions and control bleeding.

G: Incorrect. Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.

- Capillary refill time is a test that measures how quickly the blood returns to the tissues after pressure is applied and released on a nailbed or a fingertip. It is an indicator of peripheral circulation and tissue perfusion.
- To perform the capillary refill test, the examiner should press firmly on the nailbed or fingertip for a few seconds, then release the pressure and observe how long it takes for the normal color to return. The normal capillary refill time is less than 2 seconds .
- In the photo, the practical nurse (PN) applies and then releases pressure to a client's fingernail. Normal nail color returns in 2 seconds, which indicates a normal capillary refill time and adequate peripheral circulation. This is a normal and expected finding that does not require any further action, except for documentation.
- Therefore, option D is the correct answer, as it reflects the appropriate and standard nursing practice of documenting any assessment findings in the client's chart. Option D also implies that the PN does not need to report, observe, or repeat anything else related to the capillary refill test, as it was done correctly and yielded normal results.

- Options A, B, and C are incorrect answers, as they do not reflect the appropriate or necessary actions for the PN to take after performing a normal capillary refill test.
Option A is incorrect because there are no abnormal findings to report to the charge nurse, as the capillary refill time was normal.
Option B is incorrect because blanching of the nailbed is what happens when pressure is applied, not when
it is released, and it is not an abnormal finding.
Option C is incorrect because repeating the process with a different nailbed is not necessary, as the capillary refill time was normal on the first nailbed.