A nurse is reinforcing teaching about sexual activity during pregnancy for a client in a monogamous, same-sex relationship. Which of the following statements should the nurse make?

Rationale for Correct Options:

• Heart rate. The heart rate has increased from 90/min on Day 1 to 132/min on Day 2. This significant elevation is concerning for worsening systemic inflammation, hypovolemia, or sepsis and requires immediate intervention.
• Respiratory status. The client initially had diminished breath sounds at the lung bases, but by Day 2, breath sounds are diminished throughout. This suggests worsening respiratory function, possibly due to acute respiratory distress syndrome (ARDS) or pleural effusion, both of which can complicate severe pancreatitis. Immediate assessment and intervention are necessary.
• Mental confusion. The client was alert and oriented on Day 1 but is now disoriented to person, place, and time on Day 2. This change in mental status can indicate worsening systemic inflammation, sepsis, hypoxia, or metabolic disturbances such as hypocalcemia. Immediate evaluation is needed.
• Blood pressure. While the client’s initial blood pressure was stable at 126/78 mm Hg, the current reading is not provided. If the client is experiencing hypotension, it could indicate worsening shock, requiring urgent intervention.
• Temperature. The client’s temperature increased from 37.2 °C (99 °F) on Day 1 to 38.9 °C (102 °F) on Day 2. This suggests a developing infection, such as infected pancreatic necrosis or sepsis, which requires immediate reporting and further evaluation.
• Cold, clammy skin. Cold, clammy skin is a sign of poor perfusion, which may indicate impending shock due to worsening sepsis or hypovolemia. This is an urgent finding requiring immediate attention.

Rationale for Incorrect Options:

• Urine output. The client’s urine output was documented as 60 mL/hr, which is within the normal range. There is no indication of oliguria or anuria that would require immediate reporting.
• Sodium level. The sodium level of 142 mEq/L is within the normal range and does not indicate a critical electrolyte imbalance requiring urgent intervention.
• Pain. The client’s pain has increased from 8/10 to 10/10 despite receiving morphine via a PCA pump. While pain management is crucial, worsening pain alone is not the most urgent concern compared to systemic complications like respiratory failure or hemodynamic instability.
• Serum amylase level. Although the serum amylase level is significantly elevated at 498 units/L, this is expected in acute pancreatitis and does not necessarily indicate an immediate life-threatening emergency. Trends in amylase and lipase levels are important for monitoring, but they do not require urgent reporting unless accompanied by other signs of deterioration.

A. "You might experience swollen gums while taking this medication." Phenytoin is known to cause gingival hyperplasia, which is swelling and overgrowth of the gums. This is a common side effect, and clients should be informed about it so they can maintain good oral hygiene and seek dental care if necessary.
B. "You can skip a dose of this medication if you are nauseated." Skipping doses is not advised. Phenytoin should be taken consistently, and skipping doses can lead to decreased seizure control. If nausea occurs, the client should contact their healthcare provider for guidance.
C. "You can safely take this medication if you become pregnant." Phenytoin is classified as a Category D medication, indicating evidence of risk to the fetus. Women of childbearing age should discuss effective contraception and consult their healthcare provider regarding the risks associated with taking phenytoin during pregnancy.
D. "You should expect to have blood work every 6 months while taking this medication." Regular monitoring of serum levels is necessary, typically every 1-3 months, especially after dosage changes. Monitoring ensures therapeutic levels and prevents toxicity, so stating that blood work is only required every 6 months may be insufficient.