A nurse is caring for a client who is at 37 weeks of gestation and experiences a spontaneous rupture of membranes before labor has begun. Which of the following actions should the nurse take?

Rationale:
A. The client reports a pain level of 2 on a 0 to 10 scale after administration of pain medication: A pain level of 2 indicates adequate pain control following surgery, showing that the prescribed analgesic regimen is effective. This finding does not require reporting.

B. The client has a urine output of 50 mL/hr after removal of the indwelling urinary catheter: A urine output of 50 mL/hr is within normal limits and indicates adequate renal perfusion. This finding suggests that kidney function and fluid balance are appropriate after surgery.

C. The client has a wound dressing saturated with sanguineous drainage after it was reinforced: Saturation of the surgical dressing with sanguineous drainage can indicate active bleeding or hemorrhage. Because this exceeds normal postoperative drainage and persists after reinforcement, it requires immediate notification of the provider.

D. The client has an oxygen saturation level of 96% after oxygen 2 L/min via nasal cannula was applied: An oxygen saturation of 96% indicates effective oxygenation and a positive response to therapy. This finding is within normal range and does not signal a complication.

Rationale:
A. A client who has dementia and is incontinent of urine: Cognitive impairment and incontinence significantly increase the risk for pressure injuries. Dementia may limit mobility and the ability to communicate discomfort, while moisture from incontinence leads to skin breakdown, making this client the highest risk.

B. A client who has had a recent myocardial infarction: While immobility after a myocardial infarction can contribute to pressure injury risk, this client typically has fewer direct risk factors compared with incontinence and cognitive impairment.

C. A client who has a T-tube following an open cholecystectomy: Postoperative clients with a T-tube are at moderate risk due to temporary immobility, but they usually maintain mobility and can reposition, reducing overall risk compared with incontinent or cognitively impaired clients.

D. A client who is 2 days postoperative following orthopedic surgery: Early postoperative orthopedic clients are at risk due to immobility, but with appropriate repositioning, pressure-relieving devices, and monitoring, their risk is generally lower than a client with incontinence and dementia.