The nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse assesses light bilateral rales when auscultating lung sounds. Which priority action should the nurse take?

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Incentive spirometers help expand the lungs to prevent hypostatic pneumonia that can result from immobility and shallow, slow respirations. The IV rate should not be decreased as the reason for light rales is caused by immobility and the client needs fluids to replace blood loss and NPO status before the cesarean birth. Because this is indication of possible pneumonia, the nurse should institute measures to mobilize secretions, and documenting is not the priority action. Activity will be gradually increased, so ambulating around the nurses' station should not be done at this time.

The Nurse Is Caring for a Client Who Delivered by Cesarean