A client who delivered 30 minutes ago is being prepared for manual removal of the placenta. What should the nurse complete as a priority?
1. Bottle-feed the infant.
2. Send the placenta to pathology.
3. Start an IV of lactated Ringer solution.
4. Apply antiembolism stockings.
3
Explanation:
1. The client's partner or family member, or a nursery nurse, can feed the infant. The client is at risk for excessive blood loss due to retained placenta, and preparation for manual removal of the placenta is a higher priority at this time.
2. The placenta might be sent to pathology after it is removed, but preparing the client for manual removal of the placenta now is a higher priority.
3. The client undergoing manual removal of the placenta will need either IV sedation or general anesthesia. An IV is necessary.
4. Antiembolism stockings are used after major surgery that leads to immobility, thus increasing the risk of embolism. However, antiembolism stockings are not needed for this client because manual removal of the placenta is not major surgery and does not lead to postprocedure immobility.
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