A nurse is making a follow-up call to a client who has a new prescription for an ACE inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?

When transferring a client with unilateral weakness, such as hemiplegia, safety and biomechanical principles are paramount. The goal is to maximize the client’s independence by utilizing their stronger side and minimizing the risk of falls for both the patient and the nurse.

Rationale:

A. "Reach under the client's arms to pull them up" is an incorrect action. This maneuver is ergonomically unsafe for the nurse and can cause injury to the client’s shoulders, particularly the affected shoulder, which may have decreased stability or tone.

B. "Pivot the client on the foot closest to the chair" is an incorrect action. The client should be instructed to pivot on their stronger (unaffected) foot. Pivoting on the weaker foot can lead to instability and an increased risk of the client’s knee buckling.

C. "Place the wheelchair on the left side of the client" is the correct action. Because the client has right-sided hemiplegia, their left side is their stronger side. Placing the wheelchair on the client's stronger side allows them to lead the transfer with their stronger leg and arm, providing the necessary support and control during the movement.

D. "Ask the client to reach around the nurse's neck for support" is an incorrect action. This is unsafe for the nurse and the client. The client should be instructed to place their hands on the nurse's waist or shoulders (or the armrests of the chair), while the nurse maintains a safe, stable grip on the transfer belt.

This question focuses on prioritization of care for a pregnant client with severe preeclampsia. The client presents with severe hypertension, proteinuria, hyperreflexia, thrombocytopenia, and elevated liver enzymes, all consistent with preeclampsia with severe features. The provider has initiated magnesium sulfate, antihypertensives, corticosteroids for fetal lung maturity, and continuous fetal monitoring. The nurse must prioritize interventions that prevent maternal neurologic deterioration (eclampsia) while simultaneously ensuring fetal well-being through continuous assessment. Safety and rapid recognition of deterioration in both mother and fetus are the highest priorities.

Rationale for correct choices:

• Implementing seizure precautions: The client is at high risk for eclampsia due to severe preeclampsia, evidenced by severe hypertension, headache, and hyperreflexia. Seizure precautions are the first priority because seizures can lead to maternal hypoxia, fetal distress, placental abruption, and even maternal and fetal death. Interventions include padding side rails, maintaining a low-stimulation environment, keeping oxygen and suction at the bedside, and ensuring IV access is patent. Magnesium sulfate therapy is also initiated to prevent seizure activity, but safety precautions must be in place immediately.

• Reviewing fetal heart rate tracing: After initiating maternal safety measures, the nurse must assess fetal well-being because severe preeclampsia significantly increases the risk of placental insufficiency and fetal hypoxia. Continuous fetal monitoring is ordered due to the risk of decreased placental perfusion. Evaluating baseline heart rate, variability, and accelerations helps determine fetal tolerance to the intrauterine environment. Early identification of fetal compromise allows timely obstetric intervention, including possible delivery.

Rationale for incorrect choices:

• Administering betamethasone IM: Betamethasone is important for promoting fetal lung maturity in anticipation of possible preterm delivery, but it is not the first priority. Maternal stabilization and prevention of seizures take precedence before elective medications. While it improves neonatal outcomes, it does not address the immediate life-threatening risks of eclampsia. It should be administered after safety and monitoring priorities are established.

• Inserting an indwelling urinary catheter: A urinary catheter is important for strict input and output monitoring, especially to assess renal perfusion and urine output during magnesium sulfate therapy. However, it is not the immediate first action compared to seizure prevention and fetal assessment. Maternal neurologic stability must be ensured before procedural tasks.

• Administering acetaminophen PO: Acetaminophen may help reduce headache discomfort, but it does not treat the underlying cause of severe preeclampsia or prevent seizures. Pain control is not the priority in a life-threatening hypertensive emergency. The client’s neurological and vascular status requires urgent intervention before symptom relief. Therefore, this is a lower-priority action.