A client who was a victim of a rape and was confirmed HIV positive six months ago arrives at the clinic for an appointment.

The client is thin, with a saddened affect and talks about frequently crying and feeling hopeless.

The client describes not wanting to see anyone or go out of the house.

Which action should the nurse take?

Choice A rationale: Oxygen saturation of 56% is critically low and indicates severe hypoxemia, which requires immediate intervention to improve oxygenation and prevent life-threatening complications.

Choice D rationale: Tracheal deviation to the right suggests a possible tension pneumothorax, which is a medical emergency. It requires immediate attention to relieve the pressure on the affected lung and restore normal breathing.

Choice B rationale: Crackles heard in the right lung indicate fluid or atelectasis but are not immediately life-threatening compared to the other findings.

Choice C rationale: A pH of 7.21 indicates acidemia and respiratory acidosis but is a secondary concern compared to the immediate need to address the client's hypoxemia and potential tension pneumothorax.

Choice A rationale: Active labor with moderate contractions indicates that the cervix is dilating and the client is progressing in labor. It signifies that the client is experiencing significant pain and discomfort, making her a candidate for epidural anesthesia for pain relief.

Choice B rationale: Pain reported as 7/10 on a numeric pain scale indicates that the client is experiencing severe pain. Epidural anesthesia is effective in managing severe labor pain and improving the client's comfort during the birthing process.

Choice C rationale: Membranes are intact does not indicate that the client is ready for epidural anesthesia. The status of the membranes does not affect the timing of administering epidural anesthesia.

Choice D rationale: Fetal heart rate is reactive with moderate variability indicates that the fetus is in good condition and tolerating labor well. Epidural anesthesia can be safely administered when fetal monitoring shows reassuring signs.

Choice E rationale: IV line has been initiated is a necessary step for administering epidural anesthesia, but it does not alone indicate that the client is ready for the procedure. Other indicators of labor progression are needed.

Choice F rationale: Blood pressure is 130/80 mmHg indicates that the client's blood pressure is within normal limits. While it's important to have stable vital signs before administering an epidural, this alone does not indicate readiness for the procedure.

Choice G rationale: Temperature is 99.0°F (37.2°C) is within the normal range and does not affect the timing of administering epidural anesthesia. Temperature monitoring is important, but it is not a primary factor in determining readiness for an epidural.