A nurse is reinforcing teaching about the facility's fire intervention plan with new assistive personnel. Which of the following instructions the nurse include in the teaching?

Rationale:

A. Increased urinary output: Diuresis is expected within the first 12 to 24 hours postpartum as the body eliminates excess fluid retained during pregnancy. Increased urinary output helps reduce blood volume and interstitial fluid accumulated during gestation, making this a normal finding.

B. Temperature 38.2° C (100.0° F): A slight elevation in temperature can occur postpartum due to dehydration or breast engorgement, but 38.2°C is at the upper limit and may suggest infection if persistent. Therefore, it should be monitored rather than considered a typical finding.

C. Presence of lochia serosa: At 12 hours postpartum, lochia rubra, which is bright red and contains blood and tissue debris, is expected. Lochia serosa, which is pink or brown and more serous, typically appears around day 4 postpartum.

D. Deep tendon reflexes 3+: Reflexes of 3+ are slightly brisker than normal and may indicate neurological irritability or preeclampsia if seen with other symptoms. A normal postpartum reflex should be 2+, so this finding requires further evaluation.

Rationale:

 • Obtain IV access is the first priority because the client is showing signs of hypovolemic shock low blood pressure (76/45 mm Hg), tachycardia (HR 121/min), pale mucous membranes, and diaphoresis likely due to GI bleeding. Immediate vascular access is necessary for resuscitation and fluid administration.

 • Call the surgical suite to notify that the client is arriving STAT would delay essential stabilization. Transporting an unstable client without securing IV access and fluid resuscitation could worsen their condition and is unsafe.

 • Place the client in a supine position with feet elevated (modified Trendelenburg) might temporarily improve venous return, but it does not address the underlying fluid deficit. It is not a substitute for urgent fluid replacement via IV access.

 • Recheck the client's oxygen saturation is not a priority because the client already has a stable oxygen saturation of 98% on room air. The immediate threat is circulatory collapse, not hypoxia.

 • Prepare to administer IV fluids follows IV access to treat hypotension and restore circulating volume. IV fluids help stabilize hemodynamics while awaiting further interventions like endoscopy or blood transfusion if needed.

 • Transport the client for endoscopy is inappropriate at this moment because the client is hemodynamically unstable. Endoscopy is important but must be delayed until the client is stabilized.

 • Check the ECG may be useful if cardiac concerns arise due to hypotension or tachycardia, but it does not take precedence over immediate circulatory support in this scenario.

 • Check arterial blood gases would not provide data that immediately changes the management. The client's O2 saturation is normal, and ABGs are not needed to diagnose or treat hypovolemic shock due to GI bleeding.