Exhibit 1: Delivery Summary Delivery Record Vaginal delivery 40 minutes ago Estimated blood loss: 1,050 mL Fundus remains boggy despite fundal massage Oxytocin infusion is running Exhibit 2: Medical History Medical History Chronic hypertension treated with labetalol Mild intermittent asthma (uses albuterol inhaler PRN) No medication allergies Exhibit 3: Current Assessment Assessment BP: 170/104 mm Hg HR: 126/min RR: 24/min Fundus boggy with heavy lochia Two large-bore IVs in place Question The healthcare provider writes several orders. Which orders should the nurse question? Select all that apply.

A client with major depressive disorder has been taking sertraline for 10 days. During the follow-up visit the client states, “I don’t feel much happier, but I finally have enough energy to start taking care of things.” Which nursing action is most appropriate?

A nurse is caring for a client 1 hour after a vaginal delivery complicated by postpartum hemorrhage. The uterus is firm after administration of oxytocin and fundal massage. The client is restless and pale. Assessment findings include heart rate 136/min, blood pressure 86/48 mm Hg, respiratory rate 32/min, oxygen saturation 95% on room air, and urine output of 10 mL during the past hour. Which nursing intervention is the priority?

A nurse is caring for a client 45 minutes after a vaginal delivery. Despite continuous fundal massage, the uterus remains soft and poorly contracted, and the client continues to have heavy vaginal bleeding. The client’s blood pressure is 168/102 mm Hg, heart rate is 118/min, and the healthcare provider has been notified. Which nursing intervention should the nurse anticipate next?

A nurse is completing a focused postpartum assessment on a client approximately 75 minutes after an uncomplicated vaginal birth. The client reports increasing pelvic pressure and lightheadedness. Assessment findings include a uterus palpated 2 cm above the umbilicus that feels soft and poorly defined. A newly applied perineal pad is noted to be completely saturated before the nurse completes the assessment, and several small clots are present. Which nursing intervention should the nurse perform first?

A nurse is assessing a client 6 hours after a vaginal delivery. The client voided 100 mL approximately 2 hours ago but now reports increasing lower abdominal discomfort. Assessment reveals a uterus that is firm but displaced to the right and palpated 2 cm above the umbilicus. Lochia rubra is moderate without clots. Which nursing action should the nurse implement first?

A nurse is reviewing the medical records of four postpartum clients. Which client is at the greatest risk for developing a postpartum infection?

A 67-year-old client is admitted to the intensive care unit with septic shock secondary to pneumonia. Twelve hours after admission, the nurse notes new petechiae over the client’s chest, oozing of blood from the central venous catheter insertion site, and blood-tinged urine in the urinary catheter tubing. Which laboratory finding would most strongly support the nurse’s suspicion that the client is developing disseminated intravascular coagulation (DIC)?

A nurse is assessing a client 3 weeks after a vaginal delivery. The client states, “I dread waking up every morning. I cry several times a day, I don’t enjoy being with my baby, and I feel like everyone would be better off without me.” Which nursing response is the priority?

A nurse is reassessing a client 2 hours after an uncomplicated vaginal birth. The client has moderate vaginal bleeding. The uterus is firm, midline, and remains well contracted after fundal massage. Which additional assessment finding is the highest priority for the nurse to report to the healthcare provider?