A nurse on a postpartum unit is caring for a client.

Exhibits

For each finding, click to specify if the finding is consistent with uterine atony or infection. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row. (Note: Each column must have at least 1 response option selected)

Rationale:

A. Request a change in medication from the provider: Medication adjustments should be based on a full assessment of the child’s symptoms and patterns. Requesting a change prematurely may lead to ineffective or inappropriate treatment.

B. Refer the family to a chronic pain support group: Support groups are helpful for long-term coping and education, but they are not an immediate action. The nurse must first assess the current situation to guide any referrals.

C. Set up an appointment with the school nurse: While school involvement can support symptom management, especially for triggers or academic impact, it is not the initial step. The nurse must first gather complete data on the headaches.

D. Review the child's electronic pain diary: The pain diary provides detailed information about frequency, triggers, intensity, and patterns of the migraines. Reviewing it is the first step to making informed decisions about the child’s care plan.

Rationale:

A. Monitor the client for hypertension: Epidural anesthesia commonly causes hypotension due to sympathetic nervous system blockade, not hypertension. Monitoring for hypotension is more appropriate.

B. Have protamine sulfate available at the bedside: Protamine sulfate is the antidote for heparin, not epidural anesthesia. It has no relevance in managing epidural-related effects during labor.

C. Reposition the client side-to-side each hour: Changing positions frequently helps promote venous return, enhance placental perfusion, and reduce the risk of pressure injuries and aortocaval compression from a supine position.

D. Decrease the maintenance infusion rate of IV fluid: IV fluids are typically increased before and during epidural anesthesia to prevent or manage hypotension, not decreased. Reducing the rate could worsen hypotension.