A nurse is preparing to assist with the administration of medications to a client who is 72 hr postpartum following a caesarean birth.

Exhibits

Complete the following sentence by using the lists of options.

Which of the following medications requires clarification prior to administration?

The nurse should clarify the prescription for

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because

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A. "You should feed your baby six times a day." Newborns typically need to breastfeed 8 to 12 times per day, about every 2 to 3 hours, to ensure adequate nutrition and growth. Feeding only six times per day may not provide enough milk intake, increasing the risk of dehydration and poor weight gain.
B. "You should wake your baby at least every 6 hours at night for feedings." Newborns should be woken for feedings at least every 3 to 4 hours if they do not wake on their own, especially in the first few weeks. Longer intervals between feedings can lead to inadequate nutrition, dehydration, and poor weight gain.
C. "You should recognize that your baby sucking on his hands is a hunger cue." Early hunger cues include rooting, sucking on hands, smacking lips, and increased alertness. Crying is a late hunger cue, meaning the baby may already be overly hungry and difficult to calm for feeding. Recognizing early hunger cues helps ensure a smooth and effective feeding process.
D. "You should feed your baby for 10 minutes on each breast." The length of time a baby feeds on each breast varies. It is important to allow the baby to feed for as long as needed to ensure they receive both foremilk (watery milk for hydration) and hindmilk (higher-fat milk for satiety and growth). Strict time limits can lead to inadequate milk transfer and poor weight gain.

• Blood pressure. The client’s blood pressure is severely elevated (162/110 mm Hg), indicating severe preeclampsia. Uncontrolled hypertension increases the risk of stroke, placental abruption, and eclampsia (seizures). Immediate interventions such as antihypertensive medications (e.g., labetalol or hydralazine) should be initiated to lower blood pressure and prevent complications.
• Respiratory rate. The client’s respiratory rate is 20/min, which is within the normal range (12–20/min). There is no indication of respiratory distress or compromise, making this a lower priority.
• Deep tendon reflexes. The client has 3+ deep tendon reflexes, which suggest neuromuscular irritability, a sign of worsening preeclampsia. However, while hyperreflexia is concerning, severe hypertension poses a more immediate risk of stroke or seizure, making it the first priority.
• Platelet count. The client’s platelet count is critically low (95,000/mm³), which is a hallmark of HELLP syndrome (Hemolysis, Elevated Liver Enzymes, and Low Platelets). Low platelets increase the risk of bleeding complications, particularly in cases of delivery, epidural anesthesia, or cesarean section. Monitoring for further platelet decline and signs of HELLP progression (right upper quadrant pain, worsening liver function, or increased hemolysis) is essential.
• Hematocrit. The client’s hematocrit is 35%, which is within the normal range for pregnancy (33–47%). Although anemia is present (Hgb 10 g/dL), it is not an immediate life-threatening concern, making it a lower priority than the platelet count.
• Peripheral edema. The client has +2 pitting edema, which is common in preeclampsia, but it is not as critical as severe hypertension or thrombocytopenia. While worsening edema can indicate fluid retention and organ dysfunction, it does not require immediate intervention compared to other findings.