A nurse is providing end-of-life care to a client. Which of the following actions should the nurse take?

Postoperative care following an above-the-knee amputation focuses on pain control, prevention of contractures, wound healing, and early mobility to promote functional independence. Early rehabilitation is essential to prepare the residual limb for prosthetic fitting and long-term mobility. Interventions that enhance upper body strength and facilitate repositioning are key components of recovery. Proper positioning and wound care are also important to prevent complications such as contractures and infection in clients recovering from an Above-the-knee amputation.

Rationale:
A. Encouraging the use of an overbed trapeze promotes upper body strength, independence in repositioning, and early mobility. It allows the client to assist in turning, transferring, and performing activities of daily living, which are critical for rehabilitation after amputation. Strengthening the upper extremities supports future use of assistive devices and prosthetic training.

B. Maintaining abduction of the residual limb with a pillow is incorrect because it increases the risk of hip flexion contractures. Prolonged flexion or improper positioning can interfere with prosthetic fitting and long-term mobility. The residual limb should be positioned in neutral alignment rather than abducted with a pillow.

C. Cautioning the client to avoid a prone position is incorrect because prone positioning is actually recommended to prevent hip flexion contractures. Regular prone positioning helps maintain hip extension and preserves proper alignment of the residual limb. Avoiding this position may increase the risk of long-term mobility limitations.

D. Keeping a loose, absorbent dressing over the surgical site is appropriate for wound care but does not directly promote independence or mobility. While proper dressing management is essential for infection prevention and drainage control, it does not contribute significantly to functional rehabilitation goals compared to mobility-enhancing interventions.

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.