A nurse is caring for a client.

Exhibits

Which of the following interventions should the nurse perform? (Click on the exhibit tabs for additional information about the client.
There are three tabs that contain separate categories of data.)

Choice A rationale

Bradycardia, or a heart rate below 60 beats per minute, is inconsistent with decreased cardiac output in this context. Tachycardia is a more typical compensatory response to significant blood loss postpartum.

Choice B rationale

A flushed face is not a physiological indicator of decreased cardiac output. Decreased cardiac output commonly leads to pallor and cool, clammy skin due to reduced peripheral perfusion.

Choice C rationale

Hypotension, defined as blood pressure below 90/60 mmHg, occurs due to reduced blood volume and cardiac output in excessive postpartum bleeding, impairing adequate perfusion to organs and tissues.

Choice D rationale

Polyuria, or excessive urination, does not directly indicate decreased cardiac output. Instead, oliguria or decreased urine output, often below 30 mL/hour, is a common sign of poor perfusion.

Choice A rationale

Administering prophylactic antibiotics is essential when there is infection risk, but this intervention is not directly related to managing hemorrhage or neonatal nerve palsy.

Choice B rationale

Jaundice assessment is critical for newborns with facial bruising or cephalohematoma, as bilirubin levels may rise due to blood breakdown in the localized hematoma.

Choice C rationale

Monitoring vital signs ensures maternal stability, though it does not directly address hemorrhage risk or neonatal complications like nerve palsy.

Choice D rationale

Educating the client on breastfeeding techniques provides essential support but does not focus on managing cephalohematoma-related neonatal conditions.