A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?

Choice C rationale:

Hypotension is a finding that indicates the client is experiencing decreased cardiac output. Excessive vaginal bleeding can lead to hypovolemia, reducing the volume of blood pumped by the heart and resulting in decreased cardiac output. The body responds to hypovolemia and decreased cardiac output by trying to maintain blood pressure, which leads to hypotension.

Choice A rationale:

Bradycardia is not a finding indicating decreased cardiac output in this scenario. While bradycardia (abnormally slow heart rate) can be associated with decreased cardiac output in certain situations, it is not the primary finding in a postpartum client experiencing excessive vaginal bleeding.

Choice B rationale:

A flushed face is not an indicator of decreased cardiac output. A flushed face may result from various factors such as fever or emotional stress, but it is not directly related to cardiac output.

Choice D rationale:

Polyuria (excessive urination) is not an indicator of decreased cardiac output. Polyuria may occur due to factors like diuresis or increased fluid intake but is not directly related to cardiac output in the context of excessive vaginal bleeding.

Choice A rationale:

Assessing for bladder distention is important for postpartum clients, especially those who have undergone perineal trauma during childbirth. However, it is not the priority assessment during a sitz bath. The sitz bath is usually done to promote healing and comfort, and monitoring pulse rate takes precedence to identify any adverse reactions.

Choice B rationale:

Pulse rate should be the priority assessment during a sitz bath for a postpartum client. Sitz baths can cause vasodilation, leading to a potential drop in blood pressure, increased heart rate, or dizziness. Monitoring the pulse rate helps identify any cardiovascular changes or adverse reactions.

Choice C rationale:

Respiratory rate is not the priority assessment during a sitz bath. It is essential to monitor, but it is less likely to be affected directly by the sitz bath compared to the pulse rate and cardiovascular changes.

Choice D rationale:

Monitoring the color of lochia is essential for assessing postpartum bleeding and uterine healing. However, during a sitz bath, the priority assessment should be focused on cardiovascular changes and any adverse reactions the client might experience.