A nurse is caring for a 24-year-old female client in the post-operative unit following a horseback riding accident.

Exhibits

Which of the following assessment findings should the nurse attend to right away?

Choice A rationale

Donning appropriate personal protective equipment (PPE), including an N95 respirator mask, face shield, gown, gloves, and shoe coverings, is crucial to protect the nurse from potential exposure to the virus during close contact with a symptomatic client.

Choice B rationale

Teaching the client to wear a mask, hand wash, and maintain social distance is essential for preventing virus spread but is secondary to protecting the healthcare provider while collecting a test sample from a symptomatic client.

Choice C rationale

Informing the client to notify others about potential exposure is an important step in contact tracing, but it does not directly protect the nurse during the specimen collection procedure.

Choice D rationale

Notifying the charge nurse about the client's need for assignment to a COVID-19 designated area is important for appropriate care and isolation but does not directly address immediate protection for the nurse during the testing procedure.

Choice A rationale: Active labor with moderate contractions indicates that the cervix is dilating and the client is progressing in labor. It signifies that the client is experiencing significant pain and discomfort, making her a candidate for epidural anesthesia for pain relief.

Choice B rationale: Pain reported as 7/10 on a numeric pain scale indicates that the client is experiencing severe pain. Epidural anesthesia is effective in managing severe labor pain and improving the client's comfort during the birthing process.

Choice C rationale: Membranes are intact does not indicate that the client is ready for epidural anesthesia. The status of the membranes does not affect the timing of administering epidural anesthesia.

Choice D rationale: Fetal heart rate is reactive with moderate variability indicates that the fetus is in good condition and tolerating labor well. Epidural anesthesia can be safely administered when fetal monitoring shows reassuring signs.

Choice E rationale: IV line has been initiated is a necessary step for administering epidural anesthesia, but it does not alone indicate that the client is ready for the procedure. Other indicators of labor progression are needed.

Choice F rationale: Blood pressure is 130/80 mmHg indicates that the client's blood pressure is within normal limits. While it's important to have stable vital signs before administering an epidural, this alone does not indicate readiness for the procedure.

Choice G rationale: Temperature is 99.0°F (37.2°C) is within the normal range and does not affect the timing of administering epidural anesthesia. Temperature monitoring is important, but it is not a primary factor in determining readiness for an epidural.