Difficulty: Medium
Average Score: 94%
Simulated
Passage / Scenario
A client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min.Which of the following actions should the nurse take first?
Correct answer
A
Rationale
The correct answer is A: Collect hemoglobin and hematocrit levels. This is the first action the nurse should take to assess the client's oxygen-carrying capacity and hydration status. It provides crucial data for determining the client's overall health status. Inserting an indwelling urinary catheter (B) is not the priority unless indicated. Administering oxygen via face mask (C) is important, but assessing the client's hemoglobin and hematocrit levels takes precedence. Preparing the client to receive a plasma expander (D) should only be done after assessing the client's current status.