A nurse is caring for a client who is 1 hour postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding.

Which of the following actions should the nurse take?

The correct answer is choice a. Check the client’s serum medication level.

Choice A rationale:

Checking the client’s serum medication level is the most direct and objective method to evaluate medication adherence. It provides a quantifiable measure of the digoxin level in the blood, indicating whether the client is taking the medication as prescribed.

Choice B rationale:

Determining the client’s apical pulse rate is important for monitoring the effects of digoxin, as it can affect heart rate. However, it does not directly measure medication adherence.

Choice C rationale:

Asking the client if they are taking the medication as prescribed relies on self-reporting, which can be inaccurate due to forgetfulness or intentional non-disclosure.

Choice D rationale:

Assessing the client’s kidney function is important for dosing and monitoring potential side effects of digoxin, but it does not directly evaluate medication adherence.

Choice A rationale
Providing a stimulating environment is not recommended for infants with neonatal abstinence syndrome (NAS). These infants often have a heightened response to stimuli, and a calm, quiet environment is usually more beneficial.
Choice B rationale
While it is important to monitor the infant’s overall health, there is no specific need to monitor blood glucose level every hour in infants with NAS unless there is a separate medical indication.
Choice C rationale
Initiating seizure precautions is an appropriate action for a nurse caring for an infant with signs of NAS5. Infants with NAS are at risk for seizures, so nurses should be prepared to manage this potential complication.
Choice D rationale
Placing the infant on his back with legs extended is not recommended. Infants with NAS often have increased muscle tone and may be uncomfortable in this position.