A nurse is reinforcing discharge teaching about postpartum activity restrictions to a client who had a cesarean birth 2 days ago. Which of the following statements by the client indicates an understanding of the teaching?

Rationale:

A. Administer haloperidol via the intramuscular route: Medication may be necessary for agitation, but administering it before assessing the client’s emotional state and safety is premature and could escalate distress.

B. Collect data regarding the client’s feelings: Assessing the client’s emotional state and reasons for pacing and clenched fists helps identify triggers, enabling the nurse to choose the least restrictive intervention and promote de-escalation.

C. Obtain assistance to apply wrist restraints: Restraints are a last resort to ensure safety and should only be used after less restrictive interventions have failed and when the client poses an immediate risk to self or others.

D. Move the client into the seclusion room: Seclusion is also a restrictive intervention requiring assessment of necessity. Moving the client without first gathering data and attempting de-escalation may violate client rights and worsen agitation.

Rationale:

A. Urinary retention: Urinary retention is a potential side effect of epidural anesthesia due to blockade of sacral nerves, not necessarily a sign of unrelieved pain. It may occur even if pain is well managed, especially with regional anesthetics affecting bladder function.

B. Restlessness: Restlessness is a common behavioral indicator of unrelieved pain. When verbal reporting is limited or unreliable, restlessness may reflect discomfort, agitation, or anxiety related to inadequate pain control following procedures such as epidural administration.

C. Difficulty swallowing: Difficulty swallowing is not associated with pain from a herniated disc or the effects of an epidural. It may instead suggest upper airway or neurologic issues and should prompt assessment for complications unrelated to pain control.

D. Constipation: Constipation is more commonly linked to opioid use or immobility rather than unrelieved pain. While discomfort may contribute, constipation alone does not reliably indicate the adequacy of pain relief in clients receiving an epidural.