A nurse is caring for a client who is 1 hr postpartum.

Nurses' Notes 1200:

Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion.

1215:

Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified.

Select the 6 actions the nurse should take.

• A: Incorrect. Hospital-based hospice care is not a service provided by PACE, which is a program that offers comprehensive medical and social services to eligible older adults who wish to remain in their own homes and communities.
• D: Correct. Adult day care services are part of the PACE program, which helps older adults maintain their independence and quality of life by providing socialization, supervision, and assistance with activities of daily living.
• C: Incorrect. Telehealth for pacemaker diagnostics is not a specific service offered by PACE, which provides primary care, specialty care, prescription drugs, home health care, personal care, transportation, and other services as needed.
• B: Incorrect. Transfer to a skilled care facility is not a goal of PACE, which aims to prevent or delay institutionalization by providing coordinated care and support to older adults with chronic conditions and functional limitations.

A. A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.

B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex has a high risk of aspiration and airway obstruction due to impaired swallowing function. The client requires close monitoring and intervention until the gag reflex returns, which can take several hours or longer depending on the type and amount of anesthesia used.

C. A mother and their newborn 12 hr postdelivery have not completed the minimum recommended stay of 24 to 48 hours for uncomplicated vaginal deliveries or 72 to 96 hours for cesarean deliveries, according to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The mother and their newborn require assessment, education, support, and follow-up care to ensure their health and well-being.

D. A client who has lower extremity weakness and is newly admitted for observation has an undiagnosed condition that could indicate a serious neurological or vascular problem, such as stroke, spinal cord injury, or peripheral artery disease. The client requires diagnostic testing, evaluation, treatment, and rehabilitation to prevent further deterioration or complications.