A nurse is planning care for a client who is 12 hr postpartum and has a third-degree perineal laceration. Which of the following interventions should the nurse include in the plan?

In the context of the newborn's information, the nurse should report the following findings to the provider:

A. Coombs test result:

Explanation: The Coombs test checks for the presence of antibodies that can destroy red blood cells. In the absence of information about any specific concern or risk factors, a Coombs test result may not be immediately necessary for a term newborn. The nurse should report this finding to the provider for clarification on why the test was performed.

D. Intake and output:

Explanation: The newborn has voided only once since birth. Infrequent voiding can be a concern, and the nurse should report this to the provider for further evaluation, as adequate urine output is important to assess renal function and hydration status.

G. Mucous membrane assessment:

Explanation: Mucous membrane color and moisture are important indicators of hydration. If there are abnormalities, such as pale or dry mucous membranes, the nurse should report this to the provider for further assessment.

H. Sclera color:

Explanation: The color of the sclera can indicate jaundice in a newborn. If the sclera color appears yellow or jaundiced, the nurse should report this finding to the provider for further evaluation.

The following findings are not typically of immediate concern in the given context:

B. Glucose level:

Explanation: While glucose levels are important in certain situations, there is no information suggesting a need for immediate concern about glucose levels in this case. The nurse can monitor blood glucose levels as part of routine care but does not need to report it without specific concerns.

C. Head assessment finding:

Explanation: The information does not provide details about any abnormal head assessment findings. If there are no specific concerns mentioned, the nurse may not need to report this finding unless there are abnormalities observed during routine assessments.

E. Respiratory rate:

Explanation: The respiratory rate is not highlighted as a concern in the given information. If there are no specific abnormalities or signs of respiratory distress, the nurse may not need to report this finding without additional information.

F. Heart rate:

Explanation: The heart rate is not highlighted as a concern, and a normal Apgar score was noted at 5 minutes. If there are no specific concerns or abnormal findings related to the heart rate, the nurse may not need to report this finding without additional information.

A. Ensure the call button is within the client's reach: While having the call button within reach is important for the client to summon assistance quickly, the immediate priority is to prevent injury during a seizure. Padding the side rails takes precedence.

B. Place the suction equipment at the client’s bedside: While suction equipment may be necessary in certain situations, it is not the priority when implementing seizure precautions for a client with preeclampsia. The primary focus is on preventing injury during a seizure.

C. Pad the side rails of the client's bed : Seizure precautions aim to create a safe environment for a patient at risk of seizures. In the context of preeclampsia, the potential complication is eclampsia, which involves the occurrence of seizures. Padding the side rails of the bed is a priority because it helps prevent injury to the client during a seizure. In the event of a seizure, the client may move uncontrollably, and padding the side rails reduces the risk of injury if the client strikes the rails.

D. Dim the lights in the client’s room: Dimming the lights is not the priority when implementing seizure precautions. The focus should be on creating a safe environment to prevent injury during a seizure.