A postpartum woman who experienced a spontaneous vaginal birth 12 hours ago describes a headache that is worsening. The patient was given two regular-strength acetaminophen (Tylenol) tablets approximately 30 minutes ago but has had no relief from the pain
The most appropriate nursing action at this time is to do which of the following?
A.
Ask any visitors to leave now or stay quiet.
B.
Dim the lights in the patient's room.
C.
Notify the patient's health-care provider.
D.
Perform a comprehensive pain assessment.
ANS: D
The nurse should perform routine, comprehensive pain assessments to include onset, location, intensity, quality, characteristics, and aggravating and alleviating factors of the discomfort to provide interventions in a timely manner and to enhance effectiveness of medications. The nurse should also ask the patient to rate her pain on a standard 0-to-10 pain scale before and after interventions and to identify her own acceptable comfort level on the scale. The other actions are not warranted at this time.
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