A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse speaks a different language than the client. The client's partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data?

The correct answer is choice A. Persistent headache, B. Nausea and vomiting, C. Right epigastric pain, G. Proteinuria 2+, H. Deep tendon reflexes (DTR) 3+ bilaterally. Choice A rationale: Persistent headache is a significant symptom that can indicate increased intracranial pressure or other serious conditions, especially in a pregnant client. It requires follow-up to rule out complications such as preeclampsia. Choice B rationale: Nausea and vomiting, particularly when severe and persistent, can lead to dehydration and electrolyte imbalances. In the context of pregnancy, it can also be a sign of a more serious underlying condition that needs to be addressed. Choice C rationale: Right epigastric pain is concerning as it can be indicative of liver involvement, which is a serious complication in pregnancy. This symptom needs immediate follow-up to assess for conditions such as HELLP syndrome. Choice D rationale: Slight facial edema can be a normal finding in pregnancy, but it can also be a sign of fluid retention associated with preeclampsia. However, on its own, it is not as critical as the other symptoms listed. Choice E rationale: A heart rate of 88/min is within the normal range for adults and does not typically require follow-up unless accompanied by other concerning symptoms. Choice F rationale: Blood pressure of 140/90 mmHg is elevated and concerning in pregnancy, but it is not included in the correct answers because the other symptoms are more directly indicative of severe complications. Choice G rationale: Proteinuria 2+ is a significant finding that suggests kidney involvement and is a key diagnostic criterion for preeclampsia. This requires immediate follow-up. Choice H rationale: Deep tendon reflexes (DTR) 3+ bilaterally are hyperactive and can indicate neurological irritability, which is a concerning sign in the context of preeclampsia. This finding needs follow-up to prevent complications such as seizures. Choice I rationale: Fundal height measurement of 26 cm at 30 weeks of gestation is below the expected range and may indicate intrauterine growth restriction (IUGR) or other issues, but it is not as immediately critical as the other findings listed.

Choice A reason:

Discarding the first 10 mL of urine is a common practice for obtaining a urine sample for certain tests, but it is not specifically necessary for a urine culture. In a urine culture, the goal is to obtain a sample directly from the bladder to identify any bacteria present, so discarding the initial urine is not necessary.

Choice B reason

Donning sterile gloves prior to the procedure is the appropriate action for the nurse to take. When catheterizing a toddler for a urine culture, it is essential to maintain a sterile procedure to reduce the risk of infection and ensure the safety of the child. Using sterile gloves is a crucial step in preventing contamination during the catheterization process.

Choice C reason

The size of the catheter (12-French) mentioned in option C may not be appropriate for a toddler. The size of the catheter used for a toddler would generally be smaller, depending on the age and size of the child. The appropriate catheter size should be determined based on the child's age and condition.

Choice D reason

EMLA cream is a topical anaesthetic cream used to numb the skin before certain procedures. While it might be appropriate in some cases, it is not typically used for catheterization procedures in toddlers. Catheterization is a quick procedure, and using EMLA cream may not be necessary or practical in this situation.