A nurse is providing discharge teaching to a postpartum client who had no immunity to rubella and received the rubella immunization.Which of the following statements by the client indicates an understanding of the teaching?

Based on the assessment findings, the nurse identifies that the client is at greatest risk for developing:

1. Postpartum infection
2. Hemorrhage

Here's the

• Postpartum infection: The client has a history of prolonged rupture of membranes and is experiencing a moderate amount of lochia rubra, both of which increase the risk of infection. Additionally, she reports feeling weak, fatigued, and has a temperature of 38.5°C (101.3°F), which are signs of a possible infection.
• Hemorrhage: The moderate amount of lochia rubra and a boggy fundus above the umbilicus indicate that the client may be at risk for postpartum hemorrhage. The provider's prescription for administering oxytocin if needed also suggests a concern for uterine atony, which can lead to hemorrhage.

Choice A rationale

Blood pressure should be assessed as opioid analgesics can cause hypotension, which can be detrimental to both mother and fetus during labor.

Choice B rationale

Fetal heart rate monitoring is essential as opioids can cross the placenta and potentially cause fetal bradycardia or distress, thus necessitating close monitoring.

Choice C rationale

Deep tendon reflexes are not commonly affected by opioid analgesics and therefore are not a primary assessment when administering these medications during labor.

Choice D rationale

Blood glucose levels are not typically influenced by opioid analgesics in the context of labor, so this is not a relevant assessment for this scenario.