A nurse is preparing to obtain a blood sample from a newborn's heel. In what order should the nurse perform the procedure? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Explanation

Choice A Reason:

Peripartum cardiomyopathy is a form of heart failure that occurs during the last month of pregnancy or the first few months postpartum. Fluid restriction is often necessary to prevent fluid overload, which can exacerbate heart failure symptoms. By restricting fluid intake, the nurse helps manage the client's fluid balance and reduces the risk of worsening heart failure.

Choice B Reason:

Administering an IV bolus of fluids, such as lactated Ringer's, can increase the client's fluid volume, which is contraindicated in clients with heart failure, including peripartum cardiomyopathy. This could worsen the condition by increasing the workload on the already compromised heart.

Choice C Reason:

Assessing blood pressure is important in monitoring the client's cardiovascular status, but assessing it twice daily may not be sufficient for a client with peripartum cardiomyopathy, especially in the acute postpartum period. Blood pressure should be monitored more frequently, and any significant changes should be promptly addressed.

Choice D Reason:

Obtaining a prescription for misoprostol is incorrect. Misoprostol is a medication used for various purposes, including the prevention and treatment of postpartum hemorrhage. However, it is not a specific treatment for peripartum cardiomyopathy. The focus in peripartum cardiomyopathy management is on cardiac support and stabilization.

Explanation

Choice A Reason:

The newborn weighs less than 2.5 kg (5.5 lb). This is not a valid reason to delay the instillation of antibiotic ophthalmic ointment. Birth weight alone does not affect the timing of ointment administration.

Choice B Reason:

Instillation of eye medication can be delayed for
1 hour after birth to facilitate eye contact and parentnewborn attachment and bonding.

Choice C Reason:

Delaying treatment to wait for signs of infection could worsen the condition if present. Early intervention is crucial for preventing ophthalmia neonatorum.

Choice D Reason:

The newborn was delivered via cesarean birth. Delivery via cesarean section is not typically a reason to delay the instillation of antibiotic ophthalmic ointment. The risk of neonatal conjunctivitis from maternal infection remains, regardless of the mode of delivery.