A nurse is attending to a client.
The nurse notes the following vital signs: Heart rate 88/min, Temperature 38.2 C (100.9" F), Respiratory rate 20/min, Blood pressure 122/58 mm Hg. Based on the client’s medical record, what provider prescription should the nurse anticipate?

Choice A rationale

While it might seem helpful to offer to tell the parents for the client, it’s important to respect the client’s autonomy and confidentiality. The nurse should support the client in making their own decisions about disclosure.

Choice B rationale

It’s not necessarily true that the parents will have to be told why the client is being admitted. Confidentiality is a key aspect of healthcare, especially when it comes to sensitive issues like sexually transmitted infections.

Choice C rationale

This response is empathetic and non-judgmental. It acknowledges the client’s feelings and opens up a conversation without forcing any action. This allows the client to feel heard and supported, which is crucial in a healthcare setting.

Choice D rationale

While this response might be well-intentioned, it assumes that the parents will understand and doesn’t acknowledge the client’s fear or concern. It’s important for the nurse to validate the client’s feelings and provide support.

Choice A rationale

While determining the viability of the fetus is an important aspect of prenatal care, it is not the primary purpose of an ultrasound in this scenario. The client’s report of feeling the baby moving suggests that the fetus is likely viable.

Choice B rationale

The primary purpose of the ultrasound in this scenario is to locate the placenta. Heavy, red vaginal bleeding at 38 weeks of gestation could indicate a complication such as placenta previa, where the placenta covers the cervix. An ultrasound can help confirm this diagnosis.

Choice C rationale

Measuring the biparietal diameter is a method used to estimate fetal weight and gestational age. However, in this scenario, the client is already known to be at 38 weeks of gestation, and the sudden onset of heavy, red vaginal bleeding is a more immediate concern.

Choice D rationale

Assessing fetal lung maturity is typically done when there is a risk of preterm delivery. In this scenario, the client is already at 38 weeks of gestation, which is considered full term. The immediate concern is the heavy, red vaginal bleeding.