A nurse is speaking with the partner of a client who speaks a different language than the nurse. The partner tells the nurse that the client does not want to sign an informed consent for an urgent cesarean birth. Which of the following actions should the nurse take?

Rationale:

• Document the blood product transfusion in the client’s medical record: It is essential to record the transfusion, including time started and ended, vital signs, and any reactions. Documentation ensures traceability, supports patient safety, and meets regulatory and institutional requirements.

• Monitor the client for the first 15 min of the transfusion: The first 15 minutes are the most critical for detecting transfusion reactions, such as fever, chills, rash, or anaphylaxis. Continuous monitoring during this window allows for prompt intervention if adverse symptoms occur.

• Assist with obtaining the first unit of packed RBCs from the blood bank: RNs or authorized personnel can retrieve blood from the blood bank. Proper handling and timely transport of the blood ensure viability and reduce the risk of hemolysis or temperature-related damage.

• Assist with titrating the rate of infusion to maintain the client’s blood pressure at 90/60 mm Hg or above: Titrating transfusion rates based solely on BP is not within nursing protocol unless specifically ordered. Blood products must be infused according to prescription typically over 2 to 4 hours per unit unless a reaction or complication occurs.

• Start an IV bolus of lactated Ringer’s solution: The provider specifically prescribed a 0.9% sodium chloride bolus. Lactated Ringer’s is contraindicated during transfusions because it contains calcium, which can cause clotting when mixed with blood products.

• Discard the blood bag in the client’s trash can after the transfusion: Blood bags must be disposed of in biohazard containers to comply with infection control policies. Discarding medical waste in general trash violates safety protocols and increases contamination risk.

Rationale:

A. Anger: Anger is typically characterized by blaming others, expressing frustration, or resentment toward the situation, self, or those perceived to be responsible. It often follows denial and precedes bargaining in the stages of grief.

B. Bargaining: The statement "If only I had another day with them" reflects bargaining, a grief stage where individuals dwell on what could have been done differently to prevent the loss. This often includes hypothetical thinking or “what if” scenarios as a way to cope with the pain.

C. Denial: Denial involves refusing to accept the reality of the loss. It may manifest as disbelief or numbness, rather than expressing a desire to have more time or change past events, as seen in this client’s statement.

D. Depression: Depression in grief involves deep sadness, withdrawal, or feelings of hopelessness. While the client may be experiencing sorrow, the focus on "if only" thinking indicates bargaining more than the full emotional weight of depression.