The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.
The parent reports no signs of watery stools.
What nursing intervention should the nurse implement?

The nurse is reviewing the clients’ chart. Click to highlight areas of client history and physical that increase the risk for postpartum hemorrhage

History and Physical A 36-year-old client who is gravida 5 para 5 (GSP5) transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female. She was in labor for 25 hours and forceps were used to assist with the delivery. She was given an epidural for anesthesia that was effective. The labor and delivery nurse reported that the client had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale. Her vital signs were stable, and she was catheterized for 500 mL of light yellow urine just prior to delivery. Her spouse was at the bedside for delivery and appeared supportive. Blood type A+. Estimated blood loss was 600 mL after delivery.

Nurses’ Notes Received GSP5 client 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female. She was assisted to the bathroom where she voided 150 mL clear yellow urine. Lochia rubra moderate with small clots, no foul odor noted. Fundus firm at umbilicus. Episiotomy edges well approximated, no redness, edema, drainage, or ecchymosis. No pain, redness or swelling in calves. A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18 gauge peripheral IV in the left forearm at 125 mL/hr, with 500 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete IV antibiotic administration.

Click to highlight the aspects of the assessment that require urgent attention.

Medical History

The client has been hospitalized for 2 weeks following a house collapse during a hurricane. She was initially in the intensive care unit and has been moved to the surgical floor today for continued monitoring of her respiratory function and completion of IV antibiotic administration.

Nurses Notes

Pain assessment has been completed. The client’s pain is rated as 2 on a 0 to 10 pain scale. The client has requested sleeping medication for the night. She has shared that she keeps having distressing thoughts and memories about the house collapsing, which is preventing her from falling asleep. She states, “I used to be so happy before all of this happened. Now I can’t seem to get out of this funk I am in.” The client has also expressed a preference for a quieter area of the unit as she is currently located by the nurses’ station and is constantly disturbed by talking and alarms.

The client is a 22-year-old female with a history of asthma.

She was diagnosed at the age of 4 years old and has 2 previous hospitalizations for asthma related symptoms at ages 14 and 16. She denies smoking but drinks alcohol 1 to 2 times a week.

She reports taking edible marijuana to relieve severe premenstrual symptoms.

She came to the emergency department when she started having difficulty breathing on a hike.

She took her usual dose of albuterol, but the symptoms did not resolve.

The client’s friend called an ambulance when they noticed her difficulty in breathing.

Click to highlight the assessment findings that require immediate follow up by the nurse.

• The client is admitted to the medical floor.
• She has mild subcostal retractions and is sitting in an upright position.
• Wheezes are noted throughout the lung fields.
• The client is pale.
• She has strong peripheral pulses that are equal bilaterally.
• Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg. Oxygen saturation is 91% on room air.