A nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Choice A rationale

Rechecking all vital signs, including core temperature, is essential to assess the client's overall status and identify any changes that may indicate a worsening condition or complications such as infection.

Choice B rationale

Applying oxygen via nasal prongs at 4 L/minute helps ensure adequate oxygenation, which is crucial for patients who may be experiencing postoperative complications, including fever and increased metabolic demand.

Choice C rationale

Continuing to monitor vital signs every hour is important to detect any further changes in the patient's condition and provide timely interventions if needed. Frequent monitoring allows for close observation of trends.

Choice D rationale

Exposing the client's extremities and applying ice packs to the axilla can help reduce fever by promoting heat loss. This intervention is beneficial in managing elevated body temperature and preventing complications associated with hyperthermia.

Complete the sentence: The nurse teaches the client about the fetus's reaction to labor by explaining that early decelerations indicate head compression and assessing fetal heart rate patterns before, during, and after contractions.

Rationale for correct answer: Explaining that early decelerations indicate head compression is correct because early decelerations are typically associated with head compression during contractions. This is a common finding during labor and usually not a sign of fetal distress. It indicates that the fetus is descending through the birth canal, causing temporary compression of the fetal head, which leads to a brief decrease in heart rate.

Assessing fetal heart rate patterns before, during, and after contractions is correct because it provides a comprehensive understanding of how the fetus responds to labor. Monitoring the fetal heart rate throughout the contraction cycle helps identify patterns of variability, decelerations, and accelerations, ensuring that the fetus is tolerating labor well.

Rationale for incorrect answers: Choice A rationale: Identifying early decelerations as a sign of fetal distress is incorrect because early decelerations are generally benign and related to head compression. They are not typically a sign of fetal distress. Late or variable decelerations are more concerning and may indicate fetal distress.

Choice C rationale: Stating that early decelerations require immediate intervention is incorrect because early decelerations do not usually require immediate intervention. They are a normal finding during labor caused by head compression. Interventions are necessary for late or variable decelerations, which indicate possible fetal compromise.

Choice D rationale: Noting that early decelerations suggest umbilical cord compression is incorrect because early decelerations are not typically associated with umbilical cord compression. Variable decelerations are more likely to indicate cord compression, requiring closer monitoring and possible intervention.