A primiparous woman presents in labor with the following labs: hemoglobin 10.9 g/dL (109 g/L), hematocrit 29% (0.29), hepatitis surface antigen positive, group B Streptococcus positive, and rubella non- immune.

Which intervention should the nurse implement?

Reference Range

• Hemaglobin [Reference Range:12-16 g/dL (120-160 g/L)]
• Hematrocrit [Reference Range:Pregnant female: 37% to 47% (0.37 to 0.47 volume fraction)] Hepatitis Surface Antigen [Reference Range: negative]
• Group B Streptococcus [Reference Range: negative]

These findings suggest potential complications and compromise to the client's circulation and nerve function, which require immediate attention.

Changes in the quality of peripheral pulses indicate alterations in blood flow and may suggest vascular compromise or decreased perfusion to the affected areas. This finding requires immediate intervention to prevent further damage and ensure adequate blood supply to the extremities.

Loss of sensation to the left lower extremity can be indicative of nerve injury or impaired peripheral nerve function. It is important to assess for nerve damage and address it promptly to prevent complications and maximize the client's recovery.

Complaints of increased pain and pressure are concerning because they may indicate the development of compartment syndrome, a serious complication in which pressure within the muscles and tissues builds up to dangerous levels. Prompt intervention is necessary to relieve the pressure and prevent tissue damage.

While sloughing tissue around wound edges and weeping serosanguineous fluid from wounds are important assessment findings in the context of burn care, they do not require immediate intervention compared to the findings mentioned above. These findings should still be addressed and managed appropriately, but they are not considered immediate emergencies.

Tertiary prevention programs focus on minimizing the impact of an existing disease or condition and preventing further complications or disability. In the context of cardiovascular disease, one of the goals of tertiary prevention is to provide prompt rehabilitation for clients who have incurred disease complications.

By ensuring that clients who experience complications promptly receive rehabilitation services, the program is effectively addressing the needs of these clients and providing appropriate interventions to minimize the long-term impact of the disease. This outcome indicates that the program is successful in providing the necessary care and support to clients with cardiovascular disease.

Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign focuses on primary prevention rather than tertiary prevention.

At-risk clients receiving an increased number of routine health screenings may be an indicator of improved secondary prevention efforts, but it does not specifically measure the effectiveness of the tertiary prevention program for clients with cardiovascular disease.

Clients reporting new confidence in making healthy food choices is a positive outcome but does not directly reflect the effectiveness of the tertiary prevention program for cardiovascular disease.