A nurse is caring for a client who is in labor and just received epidural anesthesia. The client's blood pressure is 90/50 mm Hg.
Which of the following actions should the nurse take?

This client should be reassessed by the RN prior to transfer, as worsening perineal pain may indicate a hematoma, infection, or inadequate pain management. The RN should inspect the perineum, check the vital signs, and evaluate the effectiveness of the medication.

The other options are not correct because:

B .A multigravida whose peri-pad is 1/4 saturated with lochia rubra after one hour does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Lochia rubra is the red-colored vaginal discharge that contains blood and debris from the placental site, and it usually lasts for 3 to 4 days after delivery. A peri-pad that is 1/4 saturated after one hour is within the expected range of blood loss.

C. A multigravida complaining of strong afterbirth pains when breastfeeding does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Afterbirth pains are cramps caused by uterine contractions that help shrink the uterus and prevent bleeding. They are more common and intense in multiparous women and during breastfeeding, as oxytocin is released and stimulates the contractions.

D. A primigravida who passed a small clot when she sat up on the edge of the bed does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Small clots may form in the uterus or vagina due to pooling of blood during rest or anesthesia, and they are usually expelled when changing position or ambulating. As long as the clot is smaller than a plum and there is no excessive bleeding or pain, it is not a cause for concern.

A nuchal cord occurs when the umbilical cord wraps around the fetal neck completely or for 360 degrees.

In some cases, a tight nuchal cord can cause conjunctival hemorrhage and petechiae.

Choice B) is not correct because erythema toxicum is a common rash seen in newborns and is not related to a nuchal cord.

Choice C) is not correct because periauricular papillomas are benign skin growths near the ear and are not related to a nuchal cord.

Choice D) is not correct because telangiectatic nevi, also known as stork bites or salmon patches, are common birthmarks seen in newborns and are not related to a nuchal cord.