​​​​​​Patient Data

Exhibits

Review H and P, nurse's notes, and laboratory results.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress,

Rationale

A. Both baked potato with skin and raw carrots are high-fiber foods. The skin of the potato and raw carrots contain significant amounts of fiber, which can aggravate symptoms of ulcerative colitis.

B. Whole-grain cereals are high in fiber, which is not suitable for a low-fiber diet recommended for ulcerative colitis.

C. Roasted turkey is a lean protein source and generally suitable for a low-fiber diet. Canned vegetables can vary in fiber content; however, they are typically lower in fiber compared to fresh vegetables. The nurse should verify the specific type of canned vegetables to ensure they are low in fiber.

D. Fresh strawberries are high in fiber and should be avoided on a low-fiber diet.

A.Notify primary healthcare provider
The client's vital signs indicate signs of potential hypovolemic shock (low blood pressure, tachycardia, fever), and the saturated pad and sheets suggest ongoing significant bleeding. Notifying the primary healthcare provider is crucial to obtain further orders and potentially escalate care.
B. Count saturated pads per hour
Counting saturated pads per hour provides a quantitative assessment of blood loss and helps monitor the effectiveness of interventions aimed at reducing bleeding. This ongoing assessment guides further management decisions.
C. Administer 2 units of packed red blood cells (PRBC)

While blood loss is significant, initiating a blood transfusion is not typically an immediate first-line intervention unless the client shows signs of severe hemorrhagic shock or ongoing bleeding that cannot be controlled by other measures.
D. Administer 0.2 mg methylergonovine IM
Methylergonovine is a medication used to promote uterine contraction and control postpartum hemorrhage. Given the boggy fundus and significant bleeding, administering methylergonovine IM helps to contract the uterus and reduce bleeding.
E. Insert straight catheter
While maintaining accurate fluid balance is important, inserting a straight catheter is not an immediate priority compared to addressing active hemorrhage and stabilizing the client's condition.
F. Alert the emergency response team
The client's condition, with a boggy fundus, saturated pads, and ongoing bleeding, indicates a need for urgent intervention beyond routine measures. Alerting the emergency response team ensures prompt assistance and resources for managing potential hemorrhagic shock.
G. Increase the IV fluid to maximum rate
Increasing IV fluid administration helps to restore circulating volume and stabilize the client's blood pressure. This is essential in managing hypovolemia resulting from significant postpartum hemorrhage.
H. Weigh all bloody materials
Weighing all bloody materials is a method to estimate blood loss but is not as urgent as direct interventions aimed at stopping bleeding and stabilizing the client.
I. Massage fundus until firm
Massaging the fundus helps to stimulate uterine contractions, which can help control bleeding by compressing blood vessels at the placental site. A boggy fundus indicates poor uterine tone, and firming it up is crucial to prevent further hemorrhage.