The rapid response team transfers a client with sepsis to the intensive care unit (ICU). The client's white blood cell count is 28,000/mm3 (28 x 10^9/L). Which intervention should the nurse implement first?

Reference Range:

• White blood cell (WBC) [5,000 to 10,000/mm3 (5 to 10 x 10^9/L)]

Rationale:
A. Widening pulse pressure: A widened pulse pressure can indicate early shock or increased intracranial pressure, but it is not immediately life-threatening in the context of blunt chest trauma. It should be monitored, but other findings take higher priority.

B. Bilateral sonorous wheezes: Sonorous wheezes indicate airway obstruction or secretions and may require intervention such as suctioning or bronchodilators. While important, they are less immediately life-threatening than cardiac tamponade or tension physiology.

C. Muffled heart tones: Muffled heart sounds in a client with chest trauma may indicate cardiac tamponade, which is a medical emergency. It can rapidly lead to obstructive shock and death if not addressed immediately. This finding requires prompt reporting to the HCP.

D. Decreased urinary output: Oliguria can reflect hypovolemia or renal hypoperfusion and should be monitored and addressed. Although concerning, it develops over time and is not as acutely life-threatening as signs of cardiac compromise.

Choice A reason: Administering methylergonovine maleate is appropriate if the uterus is boggy, which indicates uterine atony. Uterine atony is the leading cause of postpartum hemorrhage. Methylergonovine stimulates uterine contraction, helping to firm the uterus and reduce bleeding. This is a critical intervention when indicated.

Choice B reason: Massaging a firm fundus is not appropriate. Fundal massage is only indicated when the uterus is boggy to stimulate contraction. Massaging a firm fundus can cause unnecessary discomfort and does not provide any benefit. Therefore, this action should not be anticipated.

Choice C reason: Observing lochia during palpation of the fundus is an important nursing action. Lochia provides information about the amount, color, and presence of clots, which helps assess for postpartum hemorrhage or abnormal bleeding. Monitoring lochia ensures early detection of complications.

Choice D reason: Documenting fundal height is necessary to track uterine involution. The fundus should gradually descend into the pelvis after delivery. Accurate documentation allows for comparison over time and helps identify delayed involution or abnormal findings.

Choice E reason: Determining whether the fundus is midline is essential. A fundus that is deviated to one side often indicates a distended bladder, which can interfere with uterine contraction and increase risk of hemorrhage. Assessing fundal position ensures appropriate interventions, such as assisting the client to void, if needed.