A nurse is reinforcing teaching about the facility's fire intervention plan with new assistive personnel. Which of the following instructions the nurse include in the teaching?

Rationale:

A. 2+ pitting edema of the lower extremities: Mild to moderate lower extremity edema is common in pregnancy and often seen in preeclampsia. While it should be monitored, it is not an immediate danger unless accompanied by other severe symptoms.

B. Increased hemoglobin: Hemoconcentration may occur in preeclampsia due to fluid shifting into interstitial spaces, but a mildly elevated hemoglobin alone does not warrant urgent intervention. It should be evaluated in the context of other lab and clinical findings.

C. Blood pressure 158/54 mm Hg: Although the systolic pressure is elevated, it does not meet the threshold of severe hypertension (>160 systolic or >110 diastolic). This finding warrants monitoring and documentation but is not the most urgent among the listed options.

D. Client report of upper right quadrant pain: Right upper quadrant or epigastric pain can signal liver involvement in severe preeclampsia, potentially indicating HELLP syndrome. This is a critical warning sign and requires immediate attention to prevent complications such as liver rupture or seizure.

Rationale:

• Temperature: An elevated temperature of 39.3° C is consistent with an active infection like pneumonia. This finding supports the need for antibiotic treatment and does not delay administration unless linked to an adverse drug reaction.

• WBC count: A WBC count of 16,000/mm³ indicates leukocytosis, which is expected in bacterial pneumonia. It confirms infection and the need for antibiotics, not a reason to withhold cefazolin.

• Allergies: The client has a documented allergy to penicillin, which is critical because cefazolin is a cephalosporin. Cephalosporins share a similar beta-lactam structure and can cross-react in clients with penicillin allergies, increasing the risk of anaphylaxis. Reporting this ensures safe prescribing and prevents a life-threatening hypersensitivity reaction.

• Chest x-ray: The left lower lobe density confirms pneumonia. This imaging supports the clinical decision to administer antibiotics and does not warrant withholding the prescribed medication.