A 36-year-old patient who is gravida 5 para 5 (G5P5) was transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female.
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 patient 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.
Based on the assessment data, the nurse recognizes the need to intervene immediately.
Select the 5 priority interventions that the nurse should initiate based on the recent assessment.

Choice A rationale

Counting and recording the number of premature ventricular contractions per minute is not the immediate priority for a patient experiencing symptoms of angina and shortness of breath. While it is important to monitor the patient’s heart rhythm, the immediate priority is to address the patient’s symptoms and stabilize their condition.

Choice B rationale

Applying oxygen via a nasal cannula and adjusting to maintain oxygen saturation above 93% is the immediate priority for a patient experiencing symptoms of angina and shortness of breath. Oxygen therapy can help to relieve the symptoms of angina and improve the patient’s oxygen saturation.

Choice C rationale

Ensuring troponin level assessments are scheduled every 3 to 6 hours for a series of three is important for diagnosing a heart attack, but it is not the immediate priority. The immediate priority is to address the patient’s symptoms and stabilize their condition.

Choice D rationale

Initiating dim lighting, lowering alarm volumes, and controlling traffic in and out of the room area can help to create a calm and quiet environment for the patient. However, this is not the immediate priority. The immediate priority is to address the patient’s symptoms and stabilize their condition.

Choice A rationale

Monitoring an IV infusion rate on an established schedule requires assessment skills and clinical judgement to identify and respond to potential complications. This task should be performed by a registered nurse.

Choice B rationale

Titration of oxygen to prescribed parameters is a complex task that requires advanced assessment skills and a deep understanding of the patient’s condition and response to treatment. This task should not be delegated to unlicensed assistive personnel (UAP).

Choice C rationale

Inserting a urinary catheter for an uncomplicated patient is a task that can be safely delegated to UAP who have been trained and demonstrated competence in this skill. It is a routine procedure and does not require advanced assessment or decision-making skills.

Choice D rationale

Procuring platelet products from the blood bank is a task that involves handling and transporting biological materials, which requires specific knowledge and skills. This task should not be delegated to UAP.