A nurse is planning care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following interventions should the nurse include?

• 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.

Rationale:

A. Ensure that each client has a living will on file prior to treatment: While advance directives are encouraged, clients have the right to choose whether to have one, and care cannot be delayed or denied if they do not.

B. Place copies of incident reports in clients' medical records: Incident reports are internal risk management tools and should not be placed in the medical record, as this could increase legal liability and compromise confidentiality.

C. Obtain personal professional liability insurance coverage: Having individual liability coverage provides additional protection beyond employer coverage, ensuring legal and financial support if malpractice claims arise.

D. Overestimate clients' acuity to prevent short staffing: Falsifying acuity levels is unethical and can result in disciplinary action or loss of license; staffing concerns should be addressed through proper administrative channels.