A nurse is assisting with the care of a client who was recently diagnosed with endometriosis.History & Physical Nurse Notes Provider Prescriptions
Nafarelin 200 mcg 1 spray intranasally every morning and 1 spray in the opposite nostril every evening
A nurse is assisting with the care of a client who was recently diagnosed with endometriosis and began taking medication to treat the condition. Which of the following manifestations reported by the client should the nurse identity as a therapeutic effect of the medication?
(Select all that apply)

Rationale:

A. Blood pressure: Changes in blood pressure, particularly elevated blood pressure, could indicate gestational hypertension or preeclampsia, which require prompt evaluation and management, especially in the context of observed facial and lower extremity edema.

B. Respiratory rate: While respiratory rate is important, the given physical examination does not suggest any abnormalities in respiratory status. Therefore, it is not a priority finding to report in this scenario.

C. Gastrointestinal assessment findings: Gastrointestinal findings are not typically pertinent to the assessment of a routine prenatal visit at 36 weeks of gestation unless the client presents with specific gastrointestinal symptoms or concerns.

D. Cerebral manifestations: Any cerebral manifestations such as changes in consciousness, severe headache, visual disturbances, or epigastric pain could indicate preeclampsia or other neurological issues and should be reported for further evaluation.

E. Deep tendon reflexes: A patellar reflex of 3 may indicate hyperreflexia, which, in conjunction with other signs, could suggest preeclampsia. Therefore, it should be reported to the provider for further assessment.

F. Fetal heart rate: Monitoring fetal well-being is essential in prenatal care. Any abnormalities in fetal heart rate, such as persistent tachycardia or bradycardia, should be reported promptly for further evaluation.

Rationale:

A. "Administer depot medroxyprogesterone every 6 to 8 weeks" is correct, as it is the recommended dosing interval for depot medroxyprogesterone injections for contraception.

B. "Massage the site after you administer the medication" is not necessary for depot medroxyprogesterone injections and may even cause discomfort or tissue damage.

C. "Give the medication intramuscularly" is the correct route of administration for depot medroxyprogesterone injections. It is typically administered into the deltoid or gluteal muscle.

D. "Initiate depot medroxyprogesterone 14 days after the client's first day of her menstrual cycle" may be appropriate for some clients, but it depends on the specific indication for the medication. This instruction is not universally applicable for all clients receiving depot medroxyprogesterone.