The Charge Nurse Is Reviewing the Plan of Care for Maternal

The charge nurse is reviewing the plan of care for maternal clients currently admitted for postpartum care. During the course of the medical record review, which intervention requires immediate consideration for revision?

A) Daily prothrombin time (PT) measurements for coagulation assessment in a client receiving heparin for treatment of thrombophlebitis.
B) Use of the REEDA (redness, edema, ecchymosis, discharge, approximation) scale for assessment every 8 hours in the care of a client diagnosed with puerperal infection.
C) Misoprostol (Cytotec) administration to a client who demonstrates uterine atony and bleeding after receiving oxytocic medications.
D) Inserting a straight catheter to drain the overdistended bladder of a client during the early postpartum period of her care.