A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?

Rationale:

A. Initiate contact precautions: No signs of infection or communicable disease are present, so contact precautions are unnecessary.

B. Decrease lighting in the client’s room: The client is restless and later becomes lethargic, suggesting neurological irritability or worsening preeclampsia. Reducing environmental stimuli like lighting can help minimize seizures and agitation.

C. Check urinary output: The client’s urine output decreased to 20 mL in one hour, which is concerning for renal impairment often seen in severe preeclampsia. Monitoring output closely helps detect worsening kidney function and fluid balance.

D. Prepare for amniocentesis: There is no indication for amniocentesis in this clinical scenario related to preeclampsia or maternal condition.

E. Encourage bed rest: Bed rest in the side-lying position improves uteroplacental perfusion and helps control blood pressure, reducing the risk of complications from preeclampsia.

F. Monitor blood pressure: Blood pressure is elevated and critical to assess frequently to evaluate disease progression and prevent hypertensive emergencies or seizures.

G. Apply internal fetal monitor: The client has no contractions and a stable external fetal heart rate. Internal monitoring is invasive and reserved for active labor or when external monitoring is insufficient.

H. Assess DTR: The shift from hyperreflexia (3+) to hyporeflexia (1+) may indicate worsening neurological status or magnesium sulfate toxicity if administered. Continuous monitoring is essential.

Rationale:

A. Possible alternative treatments: The provider is responsible for informing the client about all viable treatment options. This allows the client to make an informed decision by weighing the benefits and risks of each option.

B. Expected outcome of the procedure: Clients must understand the intended benefits and goals of the procedure. This helps them form realistic expectations and evaluate whether the procedure aligns with their preferences and values.

C. Explanation of the procedure: A clear and complete description of the procedure must be provided, including what it involves and how it will be performed. This is essential for valid informed consent.

D. Cost of the procedure: While important for financial planning, cost information is typically handled by billing or administrative staff, not required for medical informed consent by the provider.

E. Potential complications: Clients need to be informed about potential risks and complications to fully understand the implications of undergoing the procedure. This disclosure is legally and ethically required for consent.