A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads with blood in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action?

Choice A reason: Orthostatic hypotension is a normal finding in the postpartum period, because the client has a sudden decrease in blood volume after delivery. The nurse should instruct the client to change positions slowly and drink plenty of fluids.

Choice B reason: Urine output of 3,000 mL in 12 hr is a normal finding in the postpartum period, because the client has increased renal perfusion and diuresis after delivery. The nurse should encourage the client to empty the bladder frequently and monitor the intake and output.

Choice C reason: Heart rate 160/min is an abnormal finding in the postpartum period, because it indicates tachycardia, which can be a sign of infection, dehydration, hemorrhage, or cardiac complications. The nurse should assess the client's temperature, blood pressure, pulse, respirations, skin color, lochia, and pain level, and report any abnormal findings to the provider.

Choice D reason: Fundus palpable at the umbilicus is a normal finding in the postpartum period, because the uterus gradually involutes and descends into the pelvis after delivery. The nurse should palpate the fundus and check for firmness, position, and height. The fundus should be at the level of the umbilicus immediately after delivery, and descend about one fingerbreadth per day.

Choice A reason: Providing a dark, quiet environment is an appropriate action for the nurse to implement, because it can help reduce the client's blood pressure and prevent seizures.

Choice B reason: Evaluating neurologic status every 12 hr is not an appropriate action for the nurse to implement, because it is not frequent enough. The nurse should assess the client's neurologic status every 2 to 4 hr, or more often if indicated, to detect signs of cerebral edema or eclampsia.

Choice C reason: Assessing respiratory status every 8 hr is not an appropriate action for the nurse to implement, because it is not frequent enough. The nurse should monitor the client's respiratory status every 1 to 2 hr, or more often if indicated, to detect signs of pulmonary edema or respiratory depression.

Choice D reason: Ensuring that calcium gluconate is readily available is an appropriate action for the nurse to implement, because it is the antidote for magnesium sulfate toxicity. The nurse should have calcium gluconate on hand and know how to administer it in case of an emergency.

Choice E reason: Administering magnesium sulfate IV is an appropriate action for the nurse to implement, because it is the drug of choice for preventing and treating seizures in clients with severe gestational hypertension. The nurse should follow the protocol for magnesium sulfate administration and monitor the client's vital signs, urine output, reflexes, and serum magnesium levels.