A nurse is planning to apply a transdermal analgesic cream prior to inserting an IV for a preschool-age child. Which of the following actions should the nurse plan to take? (Select all that apply)

A. Notify the client's provider: This option might be considered if there are signs of postpartum hemorrhage, such as excessive bleeding, signs of shock, or a boggy uterus that does not respond to massage. However, in this scenario, the fundus is midline and firm, which indicates appropriate uterine contraction. Therefore, notifying the provider at this point may not be necessary.
B. Encourage the client to empty her bladder: Encouraging the client to empty her bladder is always important in the postpartum period, as a full bladder can impede uterine contraction. However, the presence of lochia rubra and small clots along with a midline and firm fundus suggests that uterine involution is progressing well. While encouraging the client to empty her bladder is appropriate, it may not be the priority in this situation.
C. Increase the frequency of fundal massage immediately: Fundal massage is typically performed to promote uterine involution and prevent postpartum hemorrhage. However, in this scenario, the fundus is already midline and firm, indicating adequate contraction. Increasing the frequency of fundal massage unnecessarily could cause discomfort to the client and is not indicated based on the current assessment findings.
D. Document the findings and continue to monitor the client: This is the most appropriate action at this time. The presence of lochia rubra and small clots along with a midline and firm fundus suggests that the uterus is involuting properly. Documenting the findings allows for accurate documentation of the client's condition and continued monitoring for any changes or developments. If the client's condition changes or if there are signs of postpartum hemorrhage, further action, such as notifying the provider, can be taken.

A. Open the airway using a jaw-thrust maneuver: The first step in a primary survey is to assess the airway and ensure it is open. The jaw-thrust maneuver is used to open the airway without moving the neck in case of a potential cervical spine injury.

C. Determine effectiveness of ventilator efforts: Once the airway is open, the next step is to assess breathing. This includes observing for chest rise and fall, listening for breath sounds, and feeling for air movement.

B. Establish IV access: After the airway and breathing have been assessed, circulation is the next priority. This includes establishing IV access for fluid and medication administration.

D. Perform a Glasgow Coma Scale assessment: The Glasgow Coma Scale is used to assess the client’s level of consciousness, which is part of the disability assessment in the primary survey.

E. Remove clothing for a thorough assessment: Finally, removing the client’s clothing allows for a thorough assessment of injuries. This is typically done after the immediate life-threatening issues have been addressed.