The nurse is caring for a client who had a cesarean section birth.
Which of the following would be the most important assessment to make?

Choice A rationale

Methylergonovine is a vasoconstrictor that stimulates smooth muscle contraction in the uterus to control postpartum hemorrhage. However, this vasoconstrictive effect is not limited to the uterus and can cause a systemic increase in blood pressure. The medication is contraindicated in patients with hypertension, with a systolic blood pressure greater than 140 mm Hg or a diastolic blood pressure greater than 90 mm Hg, to prevent a hypertensive crisis or cerebrovascular accident.

Choice B rationale

Hematocrit is the percentage of red blood cells in the blood and is used to assess for anemia or polycythemia. A normal hematocrit range for women is 37-47%. While anemia is a common concern postpartum, and a low hematocrit may indicate significant blood loss, it is not a primary contraindication for methylergonovine administration. The drug's primary side effect is related to blood pressure, not hematological status.

Choice C rationale

Urine output is an indicator of renal perfusion and overall hydration status. A normal urine output is typically greater than 30 ml/hr. While decreased urine output could indicate hypovolemia or renal dysfunction, it is not a direct contraindication for methylergonovine. The medication's effect on blood pressure is the primary safety consideration, not its effect on renal function or urine output.

Choice D rationale

Dizziness or lightheadedness can be a sign of orthostatic hypotension or blood loss. Assessing for dizziness is an important part of a postpartum assessment, but it is not a specific contraindication for methylergonovine. The medication's primary risk is hypertension, which is not directly related to a client's baseline experience of dizziness. A baseline blood pressure measurement is a more specific and crucial assessment.

Choice A rationale

Throwing away all stuffed animals is an unnecessary and extreme measure. The lice and nits are unlikely to survive for an extended period off the host. Sealing the items in an airtight bag for a specific duration is a more cost-effective and practical method to ensure any lice or nits are suffocated and die, preventing re-infestation.

Choice B rationale

Changing bed linen every 12 hours is not scientifically necessary. Lice and nits can survive for a limited time off the scalp, but not long enough to warrant such frequent changes. Changing and washing bedding and clothing in hot water and drying them on high heat once a day for a few days is sufficient to kill any lice or nits that may have fallen off.

Choice C rationale

Sealing all non-washable items in airtight bags for two weeks is a highly effective method. Lice and nits require a human host for survival, feeding on blood. Without a host, they will die from starvation within one to two weeks. Sealing items suffocates any remaining lice and ensures that any nits that may hatch will also die without a food source.

Choice D rationale

Soaking all hair items in alcohol is not a standard or recommended practice. While alcohol can be a disinfectant, it is not the primary method for treating lice and may damage the items. Combing with a fine-toothed nit comb, washing in hot water, or sealing items are more proven and safer methods for eradicating lice from personal belongings and preventing re-infestation.