The nurse is reviewing the client’s chart.

Click to highlight areas of client history and physical that increase the risk for postpartum hemorrhage.

Client was middle aged and married.

She was in labor for 25 hours and forceps were used to assist with the delivery.

She was given an epidural for anesthesia that was effective.

The labor and delivery nurse reported that the client had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale.

Her vital signs were stable, and she was catheterized for 500 mL of light-yellow urine just prior to delivery.

Her spouse was at the bedside for delivery.

A. Provide humidified oxygen.

Humidified oxygen adds moisture to the air, which can help to thin secretions in the airway. Thinning the secretions makes them easier to clear, particularly for patients with copious and tenacious secretions, such as those following a tracheostomy.

B. Perform chest physiotherapy prior to suctioning.

Chest physiotherapy techniques, such as percussion and vibration, can help to mobilize secretions in the lungs and airways. While this may indirectly assist in clearing secretions, it does not directly address the issue of thinning the secretions, which is the primary concern in this scenario.

C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.

Prelubricating the suction catheter tip with sterile saline before suctioning can help reduce friction and potential trauma to the airway. While this can be beneficial for airway management, it does not directly address the need to thin copious and tenacious secretions.

D. Hyperventilate the client with 100% oxygen before suctioning the airway.

Hyperventilating the client with 100% oxygen before suctioning is not recommended. It can lead to respiratory alkalosis, which is a condition characterized by decreased levels of carbon dioxide in the blood. This can worsen the client's condition and may lead to adverse effects. Additionally, it does not directly address the need to thin secretions.

Choice A rationale
Examination to determine cervical status is not an appropriate nursing action for a client who has suspected placenta previa. This may cause trauma to the placenta and increase the bleeding. The nurse should avoid any vaginal examinations or interventions unless absolutely necessary.

Choice B rationale
Magnesium sulfate infusion is not an appropriate nursing action for a client who has suspected placenta previa. This medication is used to prevent or treat seizures in clients who have preeclampsia or eclampsia, not placenta previa. It may also cause adverse effects such as respiratory depression, hypotension, and decreased fetal heart rate.

Choice C rationale
Initiation of pushing is not an appropriate nursing action for a client who has suspected placenta previa. This may worsen the bleeding and compromise the fetal oxygenation. The nurse should instruct the client to avoid any bearing down or straining.

Choice D rationale
Preparation for cesarean birth is an appropriate nursing action for a client who has suspected placenta previa. This is the preferred mode of delivery for clients who have placenta previa, especially if the bleeding is severe or the fetal distress is present. The nurse should monitor the client's vital signs, fetal heart rate, and blood loss, and notify the provider immediately.