A nurse is reviewing laboratory findings for three clients.
Which of the following laboratory results should the nurse expect for a client who has cirrhosis?

Choice A rationale:

Carrying the baby to the nursery may not align with facility security measures. Typically, hospitals have strict protocols for baby transport within the facility, including the use of identification bands.

Choice B rationale:

Taking the baby to the lobby to visit family may also not be in line with security measures. Visitors should typically come to the designated patient areas rather than taking the baby to the lobby.

Choice C rationale:

Having an identification band that matches the one the baby wears is the correct understanding of facility security measures. This ensures proper identification of the baby and helps prevent infant abduction or mix-ups.

Choice D rationale:

Removing the security band to give it to a family member is not in line with security measures. The baby's identification band should remain intact at all times to ensure proper identification and security.

Choice A rationale:

Performing a vaginal examination every 12 hours is not necessary in this case. The client is not in labor and there are no indications of any complications that would require frequent vaginal examinations.

Choice B rationale:

The client’s symptoms of severe headache, +3 pitting edema in bilateral lower extremities, and a patellar reflex of 4+ without the presence of clonus are indicative of severe preeclampsia. Antihypertensive medications are often used to manage high blood pressure in preeclampsia.

Choice C rationale:

Betamethasone is a corticosteroid that is given to pregnant women who are at risk of delivering prematurely to help mature the baby’s lungs. Given that the client is at 31 weeks of gestation and has had a previous preterm birth, administering betamethasone would be appropriate.

Choice D rationale:

A low-stimulation environment can help reduce blood pressure and prevent seizures in clients with preeclampsia.

Choice E rationale:

Bed rest can help lower blood pressure and improve blood flow to the placenta, which can be beneficial for the baby.

Choice F rationale:

Monitoring intake and output every hour can help assess kidney function, which can be affected by preeclampsia.

Choice G rationale:

A 24-hour urine specimen can provide information about protein levels in the urine, which can indicate the severity of preeclampsia. It’s important to note that normal ranges for lab parameters can vary slightly depending on the lab, but generally, protein levels in a 24-hour urine specimen should be less than 300 mg. Pitting edema is usually graded on a scale of 1+ (mild) to 4+ (severe), and a patellar reflex of 4+ is considered hyperactive and may indicate nervous system hyperexcitability seen in severe preeclampsia or eclampsia.