The nurse is caring for a postpartum client who gave birth yesterday.

The client reports that their new pad was saturated with lochia rubra within 15 minutes of changing it. The client's fundus is firm at the umbilicus.

What is the priority nursing action?

Neonatal transition assessment requires specific timing to evaluate extrauterine adaptation accurately. Knowledge of the APGAR scoring system, which measures heart rate, respiratory effort, muscle tone, reflex irritability, and color, must be applied to determine the infant's immediate clinical status.

Choice A rationale

While signs of distress require immediate intervention, APGAR scoring is a standardized tool used for all newborns regardless of clinical appearance. Waiting for distress ignores the preventive and baseline value of the scheduled one-minute and five-minute assessments.

Choice B rationale

Although providers may be present, the nurse often performs the APGAR assessment in the delivery room. Nurses are trained to evaluate the five parameters to determine if neonatal resuscitation protocols, such as positive pressure ventilation, are necessary.

Choice C rationale

Standard practice dictates APGAR scoring at one and five minutes after birth. A score of 7 to 10 is normal. If the five-minute score is < 7, assessments continue every five minutes for up to twenty minutes.

Choice D rationale

Assessing APGAR every fifteen minutes is not standard practice and would interfere with thermoregulation and bonding. Vital signs are monitored frequently during the first hour, but the specific APGAR tool is limited to the immediate transition.

Epidural anesthesia provides effective pain relief during labor by blocking nerve impulses in the spinal cord. Nurses must apply knowledge of sympathetic nervous system blockade to educate clients on common side effects, specifically hemodynamic changes that require proactive monitoring and management.

Choice A rationale

Epidural anesthesia causes sympathetic blockade, leading to peripheral vasodilation and a subsequent drop in blood pressure. Hypotension is the most frequent side effect, often requiring intravenous fluid preloading and frequent blood pressure monitoring to ensure fetal safety.

Choice B rationale

Epidural anesthesia involves local anesthetics and sometimes opioids injected into the epidural space, not the systemic bloodstream. Unlike systemic IV opioids, it does not typically cause significant drowsiness, as the primary effect is regional sensory and motor blockade.

Choice C rationale

An epidural actually decreases the sensation of a full bladder by blocking the nerves responsible for bladder awareness. Clients are less likely to feel the need to urinate and usually require intermittent or indwelling catheterization for drainage.

Choice D rationale

While uneven distribution of medication can cause one-sided numbness, lying flat on the back is contraindicated. This position causes supine hypotensive syndrome due to vena cava compression. Clients are encouraged to change sides to balance the block..