The postpartum nurse is assessing a client who gave birth by cesarean section 5 hours ago and is requesting pain medication. The client appears restless, has a heart rate of 110/min, and admits to recent onset of anxiety. What priority action should the nurse take?

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11ecbb05_cc26_fbd0_b433_a5a05806c8b1_MD0009_00 Pregnancy is a hypercoagulable state that provides protection from hemorrhage after birth, but also greatly augments risk of thrombus formation. Women who give birth by cesarean section are at particularly increased risk for deep venous thrombosis (DVT). Additional risk factors for DVT include obesity, smoking, and genetic predisposition. If unrecognized, DVT may progress to pulmonary embolism (PE), often characterized by anxiety/restlessness, pleuritic chest pain/tightness, shortness of breath, tachycardia, hypoxemia, and hemoptysis. The nurse's priority is rapidly identifying symptoms, assessing respiratory status, administering supplemental oxygen, and notifying the health care provider (HCP) (Option C). (Option A) Any redness, tenderness, or warmth in the lower extremities may indicate DVT, which should be reported to the HCP. However, the nurse's priority is addressing the client's current symptoms indicative of acute PE by assessing oxygenation. (Option B) Although relaxation breathing techniques may be helpful for management of anxiety, this client's symptoms may be stemming from impaired oxygenation secondary to PE. (Option D) Unmanaged pain can cause tachycardia; however, the additional findings of restlessness/anxiety may indicate PE. The nurse should first assess the client's oxygenation status, before administering requested pain medication. Educational objective: Pregnancy is a hypercoagulable state that increases risk for deep venous thrombosis and pulmonary embolism (PE). Signs and symptoms of PE include anxiety/restlessness, pleuritic chest pain/tightness, shortness of breath, tachycardia, hypoxemia, and hemoptysis. Priorities are rapid symptom identification, assessment of oxygenation, and notification of the health care provider.

The Postpartum Nurse Is Assessing a Client Who Gave Birth