Page the admitting anesthesiologist STAT.

Following a bowel resection, a client's tympanic temperature was 97.6°F (36.4°C) on admission to the postanesthesia care unit (PACU). Thirty minutes later, the temperature is 101.6°F (38.7°C). Which intervention(s) should the nurse implement? Select all that apply.

Choice A rationale

Assisting the client to void before walking can prevent potential incontinence episodes, which might be embarrassing for the client. Additionally, a full bladder can increase the risk of falls due to discomfort or urgency to get to the restroom quickly.

Choice B rationale

While instructing the client about signs of orthostatic hypotension is important, it is not within the scope of practice for an unlicensed assistive personnel (UAP) to provide such instructions. This task falls under the responsibility of a licensed nurse.

Choice C rationale

Measuring the client's vital signs before walking helps to assess the client's baseline status and ensures that the client is stable enough to engage in physical activity. Any abnormal readings could indicate the need to postpone or modify the activity.

Choice D rationale

Reporting the onset of any dizziness or light-headedness is crucial for ensuring the client's safety during activity. These symptoms could indicate underlying issues such as orthostatic hypotension or other cardiovascular problems that need to be addressed promptly.

Choice E rationale

Determining if a gait belt is needed ensures that the client receives appropriate support while walking. A gait belt can provide additional stability and help prevent falls, especially for clients with limited tolerance for activity.

Choice A rationale: Active labor with moderate contractions indicates that the cervix is dilating and the client is progressing in labor. It signifies that the client is experiencing significant pain and discomfort, making her a candidate for epidural anesthesia for pain relief.

Choice B rationale: Pain reported as 7/10 on a numeric pain scale indicates that the client is experiencing severe pain. Epidural anesthesia is effective in managing severe labor pain and improving the client's comfort during the birthing process.

Choice C rationale: Membranes are intact does not indicate that the client is ready for epidural anesthesia. The status of the membranes does not affect the timing of administering epidural anesthesia.

Choice D rationale: Fetal heart rate is reactive with moderate variability indicates that the fetus is in good condition and tolerating labor well. Epidural anesthesia can be safely administered when fetal monitoring shows reassuring signs.

Choice E rationale: IV line has been initiated is a necessary step for administering epidural anesthesia, but it does not alone indicate that the client is ready for the procedure. Other indicators of labor progression are needed.

Choice F rationale: Blood pressure is 130/80 mmHg indicates that the client's blood pressure is within normal limits. While it's important to have stable vital signs before administering an epidural, this alone does not indicate readiness for the procedure.

Choice G rationale: Temperature is 99.0°F (37.2°C) is within the normal range and does not affect the timing of administering epidural anesthesia. Temperature monitoring is important, but it is not a primary factor in determining readiness for an epidural.