The nurse reviews the nurse’s notes and flow chart to identify trends.

Click to specify the notations that require immediate follow up (more than one notation may be correct.)

Exhibit 1: Patient’s Medical History

• Height: 5 ft 6 in (168 cm)
• Weight: 140 lb (63.5 kg)
• Delivery: The patient was transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female.

Exhibit 2: Nurse’s Notes and Flow Sheet

The patient was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra was moderate with small clots, no foul odor noted. The fundus was firm at the umbilicus. The episiotomy edges were well approximated, with no redness, edema, drainage, or ecchymosis. There was no pain, redness, or swelling in the calves.

• Boggy fundus 1 cm above the umbilicus
• Fundus rotated to the right
• Voided 200 mL of clear yellow urine

Exhibit 3: Vital Signs

• Heart rate: 96 beats/minute
• Blood pressure: 90/62 mm Hg

Exhibit 4: Provider’s Prescriptions

• IV infusing at 125 mL/hr
• A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing.

Exhibit 5: Physical Examination Results

• Episiotomy: Intact with no redness
• Body System: Genital/Urinary and Circulatory

Choice A rationale

While securing the room with padded walls and minimal furnishings is an important aspect of seclusion, it is not the most important intervention immediately after seclusion. The safety of the client is paramount, and observing for extrapyramidal symptoms, such as dystonia, is crucial as haloperidol, an antipsychotic medication known to have the potential for causing extrapyramidal side effects, was administered.

Choice B rationale

Releasing the client as soon as composure is regained is not the most important intervention. The client’s mental and physical health needs to be continuously monitored, especially for side effects of the medication administered.

Choice C rationale

Providing one-on-one observation at all times is important, but it is not the most important intervention immediately after seclusion. The priority is to monitor for any adverse effects of the medication administered.

Choice D rationale

Observing for extrapyramidal symptoms, such as dystonia, is the most important intervention immediately after seclusion because haloperidol is an antipsychotic medication known to have the potential for causing extrapyramidal side effects.

Choice A rationale

Taking prescribed cortisone accurately is crucial for managing multiple sclerosis symptoms. Cortisone is a type of steroid that can reduce inflammation and suppress the immune system, helping to manage MS symptoms.

Choice B rationale

Using a walker when weakness occurs can be beneficial for patients with multiple sclerosis as it can help them maintain mobility and independence. However, it is not the most important instruction for the nurse to include in the discharge teaching plan.

Choice C rationale

Increasing daily intake of sodium in the diet is not recommended for patients with multiple sclerosis. High sodium intake can exacerbate symptoms of multiple sclerosis and may increase the risk of relapses.

Choice D rationale

Avoiding extreme environmental temperatures can be beneficial for patients with multiple sclerosis as heat can worsen symptoms. However, it is not the most important instruction for the nurse to include in the discharge teaching plan.