A nurse is assisting with the admission of a client to the labor and delivery unit.

Exhibits

Which of the following actions should the nurse recommend including in the client's plan of care? For each potential recommendation, click to specify if the recommendation is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

A. The client's next dressing change is scheduled in 4 hr. While the next dressing change is relevant to nursing care, it may not be critical for all members of the interprofessional team. The focus of the meeting should be on issues that impact the overall care plan and interdisciplinary collaboration.
B. The client's vital signs are checked every 8 hr. Checking vital signs every 8 hours is more specific to nursing care and may not be necessary for other team members to know unless there are concerns related to the client's condition that could affect their care.
C. The client has developed difficulty ambulating. Difficulty ambulating is important for the interprofessional team as it impacts the client's mobility, safety, and overall care plan. Difficulty ambulating may require the involvement of physical therapy, occupational therapy, and adjustments to the care approach, making it a critical point for discussion.
D. The client has state-sponsored health insurance. Having state-sponsored health insurance is relevant to the financial and administrative aspects of care, but it may not directly influence the clinical care decisions made by the interprofessional team and may not need to be addressed during the meeting.

• Administer sublingual nitroglycerin. Nitroglycerin is a first-line treatment for angina or suspected myocardial infarction. It dilates coronary arteries, improving blood flow and reducing myocardial oxygen demand.
• Apply supplemental oxygen. Routine oxygen administration is no longer recommended unless the client is hypoxic (oxygen saturation below 90%) because excessive oxygen can lead to vasoconstriction and worsen myocardial injury.
• Obtain a 12-lead ECG. While an ECG is important for diagnosing myocardial infarction, the priority in an acute chest pain episode is symptom relief and hemodynamic stability. The ECG should already have been obtained at admission.
• Administer morphine sulfate IV. Morphine is used to manage severe chest pain that is not relieved by nitroglycerin. It reduces myocardial oxygen demand, preload, and anxiety, which can help relieve symptoms.
• Monitor vital signs. Continuous monitoring is essential, but it is not the most immediate intervention in an acute episode of worsening chest pain. The focus should be on relieving ischemia and reducing myocardial workload.
• Educate the client about smoking cessation. While smoking cessation is critical for long-term cardiovascular health, education is not a priority when the client is experiencing acute chest pain requiring immediate intervention.