A nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Rationale:

A. Heart rate: Initially elevated (110/min), the client’s heart rate has decreased to 78/min by postpartum day 5, reflecting hemodynamic stability and resolution of infection-related tachycardia.

B. Temperature: Fever present on day 3 (38.6°C) has resolved by day 5 (37.1°C), indicating improved systemic response and reduced inflammation or infection.

C. WBC count: Markedly elevated at 33,000/mm³ on day 3, consistent with postpartum endometritis, has normalized to 10,000/mm³ by day 5, suggesting resolution of infection.

D. Fundal height: Uterine involution is progressing appropriately, moving from 1 cm above the umbilicus to 4 cm below by day 5, indicating the uterus is returning to its non-pregnant state.

E. Lochia: Lochia has changed from moderate, foul-smelling, dark brown on day 3 to a small amount of brownish-red with no odor by day 5, showing improvement in uterine healing and decreased infection.

F. Hemoglobin: The client’s hemoglobin has dropped from 11.1 g/dL to 10 g/dL. While still near the normal postpartum range, this decline does not represent an improvement and may indicate mild ongoing blood loss or dilutional effect.

Rationale:

A. “I can infuse the medication at a faster rate”: Vancomycin must be infused slowly, typically over 60–120 minutes, to prevent adverse effects such as Red Man Syndrome. Increasing the infusion rate is unsafe and not appropriate.

B. “I can start the medication 30 minutes earlier.” While minor time adjustments may be acceptable, this choice limits flexibility unnecessarily. Medication timing should follow institutional policy, which generally allows a 30-minute window before and a 2-hour window after the scheduled time.

C. “I have up to 2 hours after the usual scheduled time to give you this medication”: This reflects standard medication administration guidelines for time-critical medications like antibiotics. Giving vancomycin within 30 minutes before or up to 2 hours after the scheduled time is acceptable and safe.

D. “I can adjust the time and schedule for when it's convenient for you.” While patient preferences are important, antibiotic timing must align with dosing schedules to maintain therapeutic levels. Adjustments must follow clinical guidelines, not personal convenience.