The nurse has reviewed the client's chart.

Exhibits

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The nurse recognizes that this client is 

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due to 

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Rationale

A. While it is important background information, it is not directly relevant to the acute change in the client's condition (increasing confusion and agitation). Therefore, this should not be provided first in the SBAR communication.

B. Knowing the client's current medications is important for understanding any potential causes or exacerbating factors related to the sudden onset of confusion and agitation. However, this is also background information and does not immediately address the acute change in the client's condition.

C. This is the most critical piece of information to provide first in the SBAR communication. Sudden onset of increasing confusion and agitation can indicate various urgent issues such as delirium, infection, metabolic disturbances, or neurological complications. This requires immediate attention and intervention from the healthcare provider.

D. While knowing the client's healthcare power of attorney is important for ensuring appropriate decision-making if needed, it is not urgent information in the context of reporting a sudden change in the client's condition. This can be discussed later in the SBAR communication or as part of the background information if relevant to the client's care.

The nurse recognizes that this client is Hemorrhaging due to uterine atony.

Rationale

This client is likely experiencing hemorrhaging, as indicated by the boggy fundus (uterine atony), saturated pad and sheets with blood, and the significant estimated blood loss of 600 mL after delivery. Hemorrhaging refers to excessive bleeding, which can occur due to various reasons in the postpartum period, including uterine atony.

The boggy fundus (uterus) at 1 cm above the umbilicus suggests poor uterine tone, which is indicative of uterine atony. Uterine atony is a common cause of postpartum hemorrhage and occurs when the uterus fails to contract adequately after delivery, leading to excessive bleeding.