A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. The nurse should identify that which of the following actions by the AP indicates an understanding of the procedure?

A. Notify the primary care provider of the results: Notifying the provider is important for persistent hypoxemia, but the nurse should first ensure the reading is accurate. Immediate action should confirm whether the low saturation reflects true hypoxemia or a measurement error.

B. Document the finding in the medical record: Documentation is part of standard care, but it does not address the potential acute hypoxemia. Recording should occur after verifying the reading and initiating appropriate interventions if needed.

C. Repeat the test on another finger: Pulse oximeter readings can be affected by poor perfusion, nail polish, cold extremities, or device malfunction. Repeating the test on a different finger or site helps confirm the accuracy of the measurement before taking further clinical actions.

D. Consult the respiratory therapist: Referral to a respiratory therapist may be indicated if hypoxemia persists, but it is not the first action. The nurse must first verify the accuracy of the SpO2 reading to determine whether urgent intervention is necessary.

A. A client who had a cesarean delivery 24 hr ago: A medical-surgical nurse has the knowledge and skills to monitor a postoperative client, including assessment of vital signs, pain management, incision care, and early ambulation. This assignment is appropriate because it involves standard post-surgical care that aligns with the nurse’s current competencies.

B. A client who is receiving oxytocin for uterine atony: Oxytocin administration for active uterine atony requires rapid recognition of hemorrhage, titration of medication, and frequent maternal and fetal monitoring. A nurse unfamiliar with postpartum complications may not safely manage this high-risk situation, making it inappropriate for a float assignment.

C. A client who will be breastfeeding for the first time: Assisting a new mother with initial breastfeeding requires specialized knowledge of latch techniques, positioning, and management of common breastfeeding issues. A nurse without postpartum or lactation experience may not provide safe or effective guidance, making this assignment unsuitable.

D. A client who underwent removal of a retained placenta: This client is at high risk for postpartum hemorrhage and requires frequent assessment and immediate intervention if complications occur. Management of such a high-acuity postpartum client exceeds the typical scope of a medical-surgical nurse without specialized obstetric experience.