A nurse observes a client who is at 37 weeks of gestation and has preeclampsia with severe features having a seizure. Which of the following actions following the seizure should the nurse take first?

Rationale:

A. "I will expose the irradiated area of skin to the sun for no more than 30 minutes per day.": Skin that has been irradiated is highly sensitive to sunlight, and any direct exposure can increase the risk of burns and further damage. Clients should avoid sun exposure entirely on affected areas.

B. "I will apply my favorite unscented lotion to the irradiated area of skin twice each day.": Applying lotion may be appropriate if recommended by the radiation oncology team, but the client should avoid using any lotion, cream, or ointment not approved for use on irradiated skin, as some products can irritate the area.

C. "I will use my hand instead of a washcloth to wash the irradiated area of skin.": Using the hand is the safest method for cleansing irradiated skin, as washcloths can cause friction, irritation, or breakdown. Gentle washing helps protect fragile skin and prevent injury during radiation therapy.

D. "I will make sure I have sterile water to wash the irradiated area of skin.": Sterile water is not required for routine skin care of irradiated areas. Mild soap and lukewarm tap water are typically sufficient unless the provider specifies otherwise.

Rationale for correct choices

• Hypoglycemia: The newborn’s birth weight is 4200 g (9 lb 4 oz), indicating macrosomia. Infants of this size, especially after cesarean delivery, are at increased risk for hypoglycemia due to potential neonatal hyperinsulinemia. Early identification and monitoring of blood glucose are essential to prevent neurodevelopmental complications.

• Tachypnea of the newborn: The newborn demonstrates increasing respiratory rates (68 → 76/min) with grunting and mild intercostal retractions. These signs indicate transient tachypnea of the newborn, commonly seen after cesarean birth due to delayed clearance of fetal lung fluid. Continuous respiratory monitoring and supportive care are required to prevent hypoxemia or respiratory distress.

Rationale for incorrect choices

• Tachycardia: Although the newborn’s heart rate is slightly on the higher end of normal (154–156/min), it remains within the normal range for a newborn (120–160/min). This is not currently indicative of a pathologic condition or immediate risk.

• Bronchopulmonary dysplasia: Bronchopulmonary dysplasia typically occurs in premature infants who require prolonged mechanical ventilation or oxygen therapy. This term does not apply to a full-term newborn with transient tachypnea following cesarean birth.