A client at 38-weeks gestation reports severe abdominal pain. Upon palpation, the nurse notes that the abdomen is rigid. How should the nurse document the findings?

Choice A rationale

Applying a prescribed petroleum-based ointment or similar lubricant to the circumcision site after each diaper change is crucial for healing. This creates a protective barrier, preventing the raw glans from adhering to the diaper, which can cause pain and tissue damage upon removal. The ointment promotes a moist wound environment, which is conducive to optimal healing.

Choice B rationale

The umbilical cord and circumcision site are two separate areas of a newborn that require distinct care. Cleaning the umbilical cord first could introduce bacteria from one site to the other. To prevent cross-contamination and infection, it is essential to care for each area separately with clean supplies and to perform hand hygiene between each care procedure.

Choice C rationale

Using antiseptic baby wipes on the circumcision site is not recommended as the chemicals in the wipes can be irritating to the sensitive, healing tissue of the glans penis. Gentle cleaning with warm water and a soft cloth is the preferred method. Regular washing with harsh antiseptics can delay healing and cause discomfort.

Choice D rationale

Acetaminophen is an analgesic that may be prescribed for pain management, but it is not a routine part of circumcision site care. It is a medication given for pain relief, not a method of wound care. The primary care instructions focus on keeping the site clean and protected with ointment to promote healing and reduce the risk of infection.

Choice A rationale

A blood pressure of 167/107 mm Hg is classified as severe hypertension. This is an urgent and potentially life-threatening condition that requires immediate attention, not routine monitoring. Documenting the findings is part of the process, but it is insufficient as a standalone action. Delaying intervention could lead to eclampsia, stroke, or other serious complications.

Choice B rationale

Administering a prescribed antihypertensive medication is a likely intervention, but it is not the most appropriate initial nursing action without first notifying the healthcare provider. The nurse must communicate the critical change in the client's status to the provider to receive specific orders for medication, dosage, and subsequent monitoring based on the clinical picture.

Choice C rationale

A blood pressure of 167/107 mm Hg is indicative of a hypertensive crisis. The most appropriate and immediate nursing action is to notify the healthcare provider. This allows for a timely, coordinated response, including the potential for medication orders, further diagnostic tests, and a change in the plan of care to prevent an eclamptic seizure, stroke, or other end-organ damage.

Choice D rationale

While increasing the frequency of vital sign measurements is an important part of managing severe hypertension, it is not the most appropriate initial action. The primary action is to notify the healthcare provider. The provider will then likely order more frequent monitoring. The nurse must first report the critical finding to initiate the appropriate medical response.