A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

A) Increase the client's fluid intake:

While maintaining adequate hydration is essential for postpartum recovery, it is not the priority intervention in this situation. The client's increased blood loss requires immediate attention to prevent complications such as hemorrhage.

B) Prepare to administer oxytocic medication:

Oxytocic medication may be indicated to stimulate uterine contractions and control bleeding in postpartum clients experiencing excessive bleeding. However, before administering medication, assessing the client's condition and determining the cause of bleeding is necessary to ensure appropriate intervention.

C) Palpate the client's uterine fundus:

This is the priority nursing intervention. Saturating two perineal pads with blood in a 30-minute period suggests excessive bleeding, which could be due to uterine atony or other postpartum complications. Palpating the uterine fundus helps assess for uterine tone, position, and any signs of uterine atony. If the fundus is boggy or deviated from the midline, it indicates uterine atony and requires immediate intervention.

D) Assist the client on a bedpan to urinate:

While assisting the client with urination is important for comfort and prevention of urinary retention, it is not the priority intervention in this situation. Assessing and managing the cause of excessive bleeding take precedence to prevent further complications.

A) Dry the infant off and cover the head:

While drying the infant and covering the head are important steps in newborn care to prevent heat loss and maintain thermal regulation, clearing the respiratory tract takes precedence immediately after delivery to ensure adequate breathing and oxygenation.

B) Stimulate the infant to cry:

While it is essential for newborns to establish effective respiratory efforts, stimulating the infant to cry is not the first action indicated after delivery. Crying may naturally occur as a response to the new environment, but it is not a reliable indicator of effective respiratory function.

C) Cut the umbilical cord:

Cutting the umbilical cord is typically done after the initial steps of newborn care, including clearing the respiratory tract. It is important to ensure that the infant is breathing adequately before attending to other tasks such as cord cutting.

D) Clear the respiratory tract:

Clearing the newborn's respiratory tract is the priority action immediately after delivery to ensure that the airway is clear of any amniotic fluid or debris, facilitating effective breathing and oxygenation. This may involve suctioning the mouth and nose as needed to remove any secretions and ensure unobstructed airflow.