A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a client.
Which of the following actions should the nurse take first?

Choice A rationale:

A heart rate of 140/min is not a specific indicator of desmopressin effectiveness in a child with diabetes insipidus. The effectiveness of desmopressin is primarily evaluated based on the reduction in excessive urination and thirst associated with the condition. Monitoring heart rate is essential in certain situations but is not a direct measure of desmopressin efficacy in managing diabetes insipidus.

Choice B rationale:

Cessation of nocturnal enuresis (bedwetting) is a significant indication that desmopressin, an antidiuretic hormone, is effective. One of the main symptoms of diabetes insipidus is excessive urination, including during the night, leading to bedwetting. When desmopressin effectively reduces urine production, patients often experience improvement in these symptoms, including the cessation of nocturnal enuresis.

Choice C rationale:

Capillary refill of 3 seconds is a measurement used to assess peripheral perfusion and circulatory status. While it is essential to monitor capillary refill in pediatric patients, especially in cases of dehydration or circulatory compromise, it is not a specific indicator of desmopressin effectiveness in managing diabetes insipidus. Capillary refill time is more relevant in the assessment of cardiovascular function and fluid status.

Choice D rationale:

The absence of hypoglycemic episodes is not a direct indicator of desmopressin effectiveness. Diabetes insipidus is unrelated to blood glucose levels, as it involves the dysregulation of water balance due to insufficient antidiuretic hormone. While it is essential to monitor blood glucose levels in patients with diabetes mellitus, it is not relevant to assessing the effectiveness of desmopressin in treating diabetes insipidus.

The correct answers are Choices A, C, D, E, F, and G.

Choice A rationale: Antihypertensive medication is indicated due to sustained elevated BP (≥160/110 mm Hg), which increases risk for stroke, placental abruption, and eclampsia. Prompt control reduces maternal and fetal morbidity.

Choice B rationale: Routine vaginal exams are contraindicated unless signs of labor are present. Frequent exams increase infection risk and are not part of standard care for hypertensive or preeclamptic clients.

Choice C rationale: A low-stimulation environment (dim lights, quiet room) reduces CNS irritability and seizure risk in preeclampsia. It supports neuroprotection and aligns with seizure precaution protocols.

Choice D rationale: Betamethasone promotes fetal lung maturity in preterm gestation when delivery is likely. It reduces neonatal respiratory distress syndrome and improves outcomes in hypertensive pregnancies.

Choice E rationale: A 24-hour urine specimen quantifies proteinuria, essential for diagnosing preeclampsia severity. Protein 3+ on dipstick warrants confirmation via timed collection for accurate staging.

Choice F rationale: Hourly intake and output monitoring detects fluid shifts, renal compromise, and early signs of pulmonary edema. It’s critical in hypertensive disorders to guide fluid management.

Choice G rationale: Bed rest minimizes physical stress, stabilizes BP, and reduces risk of placental disruption. Left lateral positioning enhances uteroplacental perfusion and supports fetal oxygenation.