The nurse reviews the nurse’s notes and flow chart to identify trends.

Click to specify the notations that require immediate follow up (more than one notation may be correct.)

Exhibit 1: Patient’s Medical History

• Height: 5 ft 6 in (168 cm)
• Weight: 140 lb (63.5 kg)
• Delivery: The patient was transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female.

Exhibit 2: Nurse’s Notes and Flow Sheet

The patient was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra was moderate with small clots, no foul odor noted. The fundus was firm at the umbilicus. The episiotomy edges were well approximated, with no redness, edema, drainage, or ecchymosis. There was no pain, redness, or swelling in the calves.

• Boggy fundus 1 cm above the umbilicus
• Fundus rotated to the right
• Voided 200 mL of clear yellow urine

Exhibit 3: Vital Signs

• Heart rate: 96 beats/minute
• Blood pressure: 90/62 mm Hg

Exhibit 4: Provider’s Prescriptions

• IV infusing at 125 mL/hr
• A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing.

Exhibit 5: Physical Examination Results

• Episiotomy: Intact with no redness
• Body System: Genital/Urinary and Circulatory

H.

Choice A rationale

While albuterol can cause an increase in heart rate due to its beta-agonist effects, it is not the primary assessment following administration. The main goal of albuterol treatment is to improve respiratory function.

Choice B rationale

Breath sounds are a primary assessment following albuterol administration. Albuterol is a bronchodilator and should improve breath sounds by reducing bronchospasm and increasing airflow.

Choice C rationale

Serum sodium levels are not directly affected by albuterol and therefore are not a primary assessment following its administration.

Choice D rationale

A complete blood count is not directly affected by albuterol and therefore is not a primary assessment following its administration.

Choice E rationale

Oxygen saturation is a primary assessment following albuterol administration. Albuterol should improve oxygen saturation by increasing airflow and oxygen delivery.

Choice F rationale

Peak inspiratory flow is not typically assessed after albuterol administration. Albuterol primarily affects expiratory flow by reducing bronchospasm.

Choice G rationale

Temperature is not directly affected by albuterol and therefore is not a primary assessment following its administration.

Choice H rationale

Peak expiratory flow is a primary assessment following albuterol administration. Albuterol is a bronchodilator and should improve peak expiratory flow by reducing bronchospasm.

Choice A rationale

While social workers can provide support therapy, they are not typically involved in teaching medical procedures like insulin injection15.

Choice B rationale

Leaving the room and returning later can give the client time to process the information and prepare for learning. It’s important to respect the client’s feelings and readiness to learn15.

Choice C rationale

While it’s true that insulin is a life-saving drug for people with type 1 diabetes, simply explaining this may not address the client’s fears or concerns about self-injection15.

Choice D rationale

Encouraging relaxation techniques can be helpful, but it doesn’t directly address the issue of teaching insulin injection15.