A woman is brought to the labor and delivery unit after delivering a full term infant and the placenta in the hospital parking lot 10 minutes ago. What action should the nurse perform first?

Choice A: Nasogastric tube insertion may be indicated in the management of a client with peptic ulcer disease (PUD) to assess bleeding, relieve gastric distention, or administer medications. However, in this scenario, the client's presentation with sudden severe upper abdominal pain, a tender and rigid abdomen, hypotension, and tachycardia suggests a potentially life-threatening condition that requires immediate intervention beyond nasogastric tube insertion.

Choice B: Iced saline lavage is not a standard procedure for managing peptic ulcer disease (PUD) or its complications. It is not the immediate intervention required for the client's presentation.

Choice C: Administration of pantoprazole (Protonix) IV, a proton pump inhibitor, is a relevant intervention for managing peptic ulcer disease (PUD), but it may not be the most immediate action needed for a client with sudden severe abdominal pain, hypotension, and tachycardia. More urgent interventions are required.

Choice D: Emergency abdominal surgery is the most appropriate and immediate intervention for a client with sudden severe upper abdominal pain, a tender and rigid abdomen, hypotension, and tachycardia. These signs and symptoms may indicate a perforated peptic ulcer, which is a surgical emergency requiring prompt exploration and repair of the perforation to prevent peritonitis and sepsis.

A. Document the findings in the record – A bluish-black discoloration over the lumbosacral area is most likely a Mongolian spot, a benign congenital birthmark commonly seen in infants with darker skin tones. It does not require intervention, only documentation.
B. Report possible child abuse to protective services – Mongolian spots may resemble bruises, but they are not a sign of abuse. Reporting without further assessment is inappropriate.
C. Gently rub the area with skin cream to promote healing – Mongolian spots are not injuries and do not require treatment.
D. Ask the mother about the discoloration – While obtaining history is important, Mongolian spots are well-known benign findings that do not require further clarification from the parent.