A nurse is caring for a client who became physically aggressive and had to be placed in mechanical restraints. Which of the following actions should the nurse take while the client is in restraints?

• Blood pressure: At 2100, the client’s BP was 90/56 mm Hg, indicating hypotension likely from postpartum hemorrhage. By 2115, BP increased to 108/72 mm Hg, showing improved hemodynamic stability after interventions such as fundal massage, oxytocin administration, and bladder emptying.
• Skin temperature: At both 2100 and 2115, the client’s skin remained cool to the touch. This could indicate ongoing peripheral vasoconstriction or residual hypoperfusion, suggesting that although circulation improved, thermoregulation and peripheral perfusion have not fully normalized.
• Fundal assessment: Initially, the fundus was boggy, deviated to the right, and 2 cm above the umbilicus, indicating uterine atony worsened by bladder distention. After catheterization and uterotonic therapy, the fundus became midline, firm, and at the level of the umbilicus, which is expected postpartum and reduces bleeding risk.
• Bleeding: At 2100, there was heavy lochia rubra saturating a perineal pad in 20 min with passage of a large clot. At 2115, bleeding decreased to a moderate amount of lochia rubra with a few pea-sized clots, indicating that hemorrhage control measures were effective.

A. "You will be given access to the medical records of every client in the facility.": Access to electronic medical records is restricted based on the nurse’s role and need-to-know basis to protect client confidentiality. Nurses only view records of clients under their care.

B. "You will be asked to change your password once per year.": Most facilities require more frequent password changes, often every 60–90 days, to maintain system security. Annual changes alone are insufficient for protecting client data.

C. "Information Technology will install a firewall to secure client information.": Firewalls and other cybersecurity measures help protect electronic health information from unauthorized access. Including this ensures nurses understand that the system has built-in technical safeguards for privacy and security.

D. "Documentation of sensitive material is performed by the charge nurse.": All licensed nurses are responsible for accurate, complete, and timely documentation of client care, including sensitive material. Responsibility is not limited to the charge nurse.