A nurse is reviewing the medical record of a client.

Exhibits

Click to highlight below the findings that require immediate follow-up.

Body system/Findings

 Neurological- Alert and oriented to person, place, and time; deep tendon reflexes 4+

 Musculoskeletal - Generalized weakness with equal bilateral muscle strength and mild leg cramping 

 Respiratory- Lungs clear

 Cardiovascular- Heart rate irregular: Heart rate 95/min

 Gastrointestinal- Bowel sounds hyperactive x 4 quadrants 

Rationale:

A. Documenting the status of the episiotomy, including its size and approximation, is important for monitoring wound healing and ensuring appropriate postpartum care.

B. While providing self-care instructions is important, it is not a specific documentation related to the postpartum condition.

C. Fluid intake with meals is important for overall health but may not be specifically related to the postpartum condition.

D. Documenting an elevated oral temperature may be relevant for assessing the client's health status but is not specific to the postpartum condition.

Rationale for A: Providing oral care once every 8 hours is not directly related to relieving dyspnea. Oral care addresses comfort related to dry mouth, but it doesn't improve breathing difficulties.

Rationale for B: Repositioning the client every 4 hours can help alleviate dyspnea by improving lung expansion and preventing pooling of secretions. It also helps in reducing pressure injuries, promoting comfort, and preventing complications.

Rationale for C: Placing the head of the bed flat can exacerbate dyspnea by hindering lung expansion. It is recommended to elevate the head of the bed to improve air exchange and breathing.

Rationale for D: While using a fan can help with the sensation of breathlessness, repositioning every 4 hours is a more direct action to support ventilation and reduce dyspnea.