A nurse is caring for an adolescent.
Admission Assessment
1400:

• Adolescent brought to emergency department by parents following a fall while skateboarding.
• Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.
• Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm.
• Abdomen soft and nontender with active bowel sounds in all four quadrants.
• Right lower extremity with open wound and displaced bone.
• Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Select the 4 findings that require follow-up.

Choice A reason:
Determine previous coping skills used by the client is not appropriate. Assessing the client's previous coping skills is an essential step in the assessment phase of the therapeutic relationship, not specifically during the orientation phase. This information helps the nurse to understand the client's coping mechanisms and identify potential areas for improvement or support.
Choice B reason:
Facilitate the client's problem-solving skills is not appropriate the nurse may work on facilitating the client's problem-solving skills throughout the therapeutic relationship, including during the working phase. During this phase, the nurse and client collaborate to explore and address the client's concerns and challenges.
Choice C reason:
Assisting the client in expressing alternative behaviours is not appropriate. This action may also be part of the working phase, where the nurse helps the client explore alternative behaviours and coping strategies to address their issues and challenges.
Choice D reason:
The orientation phase is the initial stage of the therapeutic relationship where the nurse and the client get to know each other and establish the groundwork for their working relationship. During this phase, it is essential to clarify the roles and responsibilities of both the nurse and the client to ensure a clear understanding of each other's expectations.

A. This is a correct action. Firmly massaging the uterine fundus can help contract the uterus and reduce bleeding by expelling clots and compressing blood vessels.

B. This is a correct action. Providing emotional support can help calm the client and reduce anxiety, which can worsen bleeding by increasing heart rate and blood pressure.

C. This is a correct action. Administering oxygen can help improve tissue perfusion and oxygenation, which can prevent hypoxia and shock due to blood loss.

D. This is a correct action. Weighing the perineal pads can help estimate the amount of blood loss and monitor the effectiveness of interventions to control bleeding.

E. This is a correct action. Inserting an indwelling urinary catheter can help empty the bladder and prevent it from displacing or compressing the uterus, which can interfere with uterine contraction and increase bleeding.

F. This is a correct action. Administering methylergonovine can help stimulate uterine contraction and reduce bleeding by constricting blood vessels in the uterus.