A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxy-methamphetamine.
Which of the following findings should the nurse expect?

Choice A rationale: Writing a client's diagnosis on the message board in the client's room can expose sensitive information to anyone who enters the room, which compromises client confidentiality.

Choice B rationale: Discarding worksheets containing client information in a wastebasket is not secure and can lead to unauthorized access to confidential information.

Choice C rationale: Giving change-of-shift report to a nurse outside the client's room protects client confidentiality by ensuring that sensitive information is shared only with authorized personnel in a private setting.

Choice D rationale: While sharing relevant information with personnel directly involved in the client's care is generally acceptable, it must still be done in a manner that safeguards confidentiality.

Choice A rationale:

Performing intermittent external electronic fetal monitoring is not the best choice in this situation. The client’s condition, which includes severe abdominal pain, vaginal bleeding, rigid and tender abdomen, and late decelerations in the fetal heart rate, suggests a possible placental abruption. In such a case, continuous fetal monitoring is required to closely monitor the fetal heart rate and contractions.

Choice B rationale:

Monitoring vital signs at least every 15 min is necessary. The client’s blood pressure has dropped from 110/68 mm Hg to 95/59 mm Hg within 15 minutes. This could indicate hypovolemia due to blood loss. Regular monitoring can help detect changes early and initiate appropriate interventions.

Choice C rationale:

Placing the client in a supine position is not recommended. This position can exacerbate supine hypotensive syndrome, which occurs when the gravid uterus compresses the inferior vena cava, reducing venous return and cardiac output. A side-lying position would be more appropriate.

Choice D rationale:

Obtaining a type and crossmatch is crucial. The client’s symptoms suggest a possible placental abruption, which can lead to significant blood loss. Having blood available for transfusion can be lifesaving.

Choice E rationale:

Measuring blood loss by weighing pads can provide an objective assessment of blood loss. This can help guide treatment decisions, including the need for blood transfusion.

Choice F rationale:

Inserting a large-bore IV catheter is necessary in this situation. It allows for rapid fluid and blood replacement if needed. Given the client’s symptoms and the potential for significant blood loss with placental abruption, this intervention is appropriate.