The nurse is caring for four clients:

• Client A, who has emphysema and whose oxygen saturation is 94% on room air;
• Client B, with a postoperative hemoglobin of 8.2 mg/dL (82 g/L);
• Client C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L);
• Client D, scheduled for an appendectomy who has a white blood cell (WBC) count of 14,000 mm3 (14 x 109/L).

Which intervention should the nurse implement?Reference Range:

• Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]
• Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]
• White Blood Cell [5,000 to 10,000/mm3 (5 to 10 x 109/L)]

Convert the weight to kilograms, knowing that 1 kilogram equals 2.2 pounds. The child weighs approximately 25 kilograms (55 ÷ 2.2). Then, multiply the weight in kilograms by the prescribed amount of medication, which is 150 mg/kg/day.

So, 25 kg × 150 mg/kg/day equals 3750 mg/day.

At risk of hypovolemia

D. Total blood loss of 800 mL

A total blood loss of 800 mL indicates significant hemorrhage, which puts the client at risk for hypovolemia (low blood volume). While exact definitions may vary, typically, blood loss exceeding 500 mL postpartum is considered significant and increases the risk of hypovolemia if not managed appropriately.

F. 200 mL blood loss

While 200 mL of blood loss is within the normal range for immediate postpartum period, it still represents a loss of blood that, if ongoing, could potentially lead to hypovolemia if not monitored closely.

Condition has improved

A. Fundus massaged until firm and at umbilicus

Massaging the fundus until it is firm and at the umbilicus helps ensure uterine contraction, which reduces the risk of excessive bleeding and promotes hemostasis. This indicates that uterine tone is adequate, which is a positive sign.

C. Straight catheter produced 500 mL clear yellow urine

The passage of 500 mL of clear yellow urine indicates adequate renal perfusion and hydration status, suggesting that the client's fluid balance is being maintained or improved, which is important in preventing hypovolemia.

E. Blood pressure of 110/80 mm Hg, heart rate of 66 beats/minute, oxygen saturation at 98% on room air

Stable vital signs with normal blood pressure, heart rate, and oxygen saturation indicate adequate perfusion and oxygenation. This suggests that the client's condition is stable and not immediately at risk for hypovolemia.

G. Fundus remains firm with slight lochia noted on pad

A firm fundus with slight lochia (postpartum vaginal discharge) indicates ongoing normal involution (shrinking) of the uterus with minimal bleeding. This suggests that the client's uterus is contracting well, which is favorable for preventing hypovolemia.