The nurse is assessing the urinary output of a patient 4 hours after a caesarean birth. The patient weighs 68 kg and the indwelling catheter bag measures 125 mL of urine. Which action will the nurse include in the plan of care?

Choice A reason: Calling the healthcare provider is a valid action if the nurse encounters an unexpected issue or an emergency. However, in this situation, the nurse's immediate observation of physical signs indicating pain suggests that the patient might be experiencing discomfort. The nurse has enough clinical judgment to address the pain directly rather than waiting for a healthcare provider's intervention, which could delay relief.

Choice B reason: Waiting for the patient to report pain is not an ideal choice here because children, especially younger ones, may not always verbalize their pain even when they are in discomfort. The nurse's role involves assessing both verbal and non-verbal cues to provide timely and appropriate care. Physical signs such as clenched fists and a wrinkled forehead strongly indicate pain, necessitating prompt action rather than waiting.

Choice C reason: Administering intravenous morphine is the appropriate intervention given the clear physical signs of pain observed by the nurse. Morphine is a powerful opioid analgesic used to manage moderate to severe pain. In a post-surgical context, controlling pain effectively is crucial for the patient's recovery. Therefore, this action aligns with the need for timely pain management to ensure the child's comfort and facilitate healing.

Choice D reason: Instructing the parent to play relaxing music can be a helpful non-pharmacological intervention to provide a calming environment for the child. However, this action alone is unlikely to address the acute pain suggested by the patient's physical signs. While it can be part of a comprehensive pain management plan, the primary approach should be administering medication to relieve the immediate pain.

Choice A reason: While an oxygen saturation of 94% is slightly low, it is not an immediate emergency for a child with asthma. This patient can be monitored but does not require the nurse's immediate attention.

Choice B reason: Severe chest pain in a patient with sickle cell anaemia can indicate a serious complication known as acute chest syndrome, which is a medical emergency. This condition requires immediate assessment and intervention to prevent life-threatening complications.

Choice C reason: A urine specific gravity of 1.010 indicates dilute urine, which is typical for a patient with diabetes insipidus. While this condition requires management, it is not an immediate emergency compared to severe chest pain in a sickle cell anaemia patient.

Choice D reason: A fever of 102.2°F in a child with respiratory syncytial virus (RSV) is concerning and requires attention, but it is not as immediately life-threatening as severe chest pain in a sickle cell anaemia patient. This patient can be seen after addressing the more urgent case.

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