A nurse is caring for a client who has an ectopic pregnancy. Which of the following findings should the nurse expect?

Rationale:
A. Wear a gown when providing care: A gown should always be worn when caring for a client with C. difficile to prevent contamination of the nurse’s clothing with infectious spores. This is part of contact precautions, which are essential to stop transmission via direct or indirect contact.

B. Wash hands with an alcohol-based cleaner: Alcohol-based sanitizers are ineffective against C. difficile spores. Handwashing with soap and water is required after client contact because mechanical friction is needed to remove spores from the skin.

C. Change gloves after contact with infectious material: Gloves must be changed immediately after contact with contaminated surfaces or body fluids to prevent cross-contamination.

D. Wear an N95 respirator when providing care: An N95 respirator is unnecessary for clients with C. difficile because the infection is transmitted by contact, not airborne routes. Standard and contact precautions are sufficient for infection control.

E. Remove the thermometer from the client's room for use on another client: Equipment used for a client with C. difficile should remain dedicated to that client. Sharing devices like thermometers risks spreading spores to other clients, so disposable or patient-specific equipment must be used.

Rationale

A. Perform a vaginal examination every 12 hr: Vaginal examinations should be avoided in a client with severe preeclampsia unless delivery is imminent, as they can stimulate uterine activity and increase the risk of placental abruption. Continuous monitoring and noninvasive assessments are prioritized instead.

B. Administer betamethasone: Betamethasone promotes fetal lung maturity by stimulating surfactant production when preterm delivery before 34 weeks is anticipated. This reduces the risk of neonatal respiratory distress syndrome and intraventricular hemorrhage.

C. Provide a low-stimulation environment: A quiet, dimly lit environment helps minimize CNS stimulation, reducing the risk of seizure activity in clients with severe preeclampsia. Environmental stressors such as bright lights and loud noises should be avoided.

D. Maintain bed rest: Bed rest, particularly in the left lateral position, improves uteroplacental perfusion and reduces blood pressure by minimizing pressure on the vena cava. It also helps limit activity that could elevate BP further.

E. Obtain a 24-hr urine specimen: Collecting a 24-hour urine specimen allows accurate assessment of total protein excretion, which confirms the severity of preeclampsia. Proteinuria greater than 300 mg/24 hr indicates significant renal involvement.

F. Give antihypertensive medication: Antihypertensives such as labetalol or hydralazine help prevent maternal complications like stroke or heart failure from sustained severe hypertension while avoiding excessive BP reduction that could impair uteroplacental blood flow.

G. Monitor intake and output hourly: Close monitoring of intake and output detects early signs of renal compromise or fluid overload, which are common in preeclampsia. Accurate measurement helps guide safe fluid management and prevent pulmonary edema.