Prior to discontinuing the IV Pitocin (oxytocin), which assessment is most important for the nurse to obtain?
A) Vital signs.
Vital sign assessment is important prior to discontinuing the Lactated Ringer's since the primary IV contributes to the maintenance of cardiovascular stability.
B) Vaginal discharge.
Expulsion of minimal bright red vaginal discharge is normal after delivery. It is difficult for the nurse to ascertain client stability merely by assessing the vaginal discharge and estimating amounts of vaginal blood loss.
C) Uterine firmness.
Pitocin is a hormone used to stimulate uterine contractions and prevent hemorrhage from the placental site. Prior to discontinuing the IV, it is most important to ensure that the uterus is contracting by assessing fundal firmness.
D) Oral intake.
Assessment of oral fluid intake is important when determining if additional IV fluids are indicated, but it is not the first priority.
What is the priority nursing diagnosis for Marie, who is experiencing residual effects of epidural anesthesia?
A) Risk for infection.
The lack of sensation below the waist caused by the residual effects of epidural anesthesia does not pose any real threat of infection, because epidural side effects are unrelated to the mechanisms of infection transmission or development.
B) Risk for injury.
Epidural anesthesia causes temporary loss of voluntary movement and muscle strength in the lower extremities. Serious injury could be incurred if Marie attempts to get out of bed on her own, because her legs will be unable to sustain her weight. The nursing priority is to ensure her safety by implementing use of all four side-rails and instructing her to not get out of bed for the first time without assistance.
C) Impaired physical mobility.