A nurse on a postpartum unit is caring for a client.

Exhibits

The nurse should anticipate a provider's prescription for a(n)

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and

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.

Rationale for Correct Choices:

• Evaluating the fetal heart rate tracing: The client’s report of decreased fetal movement and severe hypertension raises concern for fetal compromise. Immediate fetal assessment ensures the fetus is tolerating the intrauterine environment, especially before administering medications like magnesium sulfate.
• Administering magnesium sulfate IV: This is prescribed to prevent eclampsia, given the client’s severely elevated BP, hyperreflexia, and proteinuria. After confirming fetal status, seizure prophylaxis should be initiated without delay.

Rationale for Incorrect Choices:

• Administering acetaminophen PO: Although ordered for headache, the symptom is a manifestation of severe preeclampsia. Treating it symptomatically without addressing its cause could delay necessary critical interventions.
• Obtaining a 24-hour urine collection: Useful for confirming the extent of proteinuria, but not immediately necessary for clinical decision-making given existing positive findings.
• Inserting an indwelling urinary catheter: This supports fluid monitoring during magnesium therapy, but fetal assessment and seizure prevention take precedence.
• Administering betamethasone IM: Important for fetal lung development in preterm pregnancies, but it is not the immediate priority when there is a high risk for seizure or fetal distress.

Rationale for Correct Choices:

• Self-harm: The client expresses suicidal ideation influenced by delusions, indicating a strong risk of acting on these impulses. In schizophrenia, command hallucinations are particularly dangerous when they involve instructions to harm oneself.
• Command hallucinations: The client reports hearing voices directing them to act, which is a hallmark of command hallucinations. These are associated with a heightened risk of harm to self or others, especially when the client appears fearful or paranoid, as in this case.

Rationale for Incorrect Choices:

• Palming medications: Although the client is suspicious and refuses medication (“I’m not letting you poison me”), there is no evidence yet of palming or hiding pills. The agitation could indicate refusal, but not covert medication avoidance.
• Poor hygiene: While the client shows confusion regarding bathing and clothing, these are not the most immediate safety threats compared to suicide risk. Poor hygiene is a concern in schizophrenia but not the most critical issue at this time.
• Impaired memory: Impaired memory is evident (e.g., forgetting routines), but this is not directly linked to a life-threatening risk. Memory issues can affect functioning but don’t explain the urgency of the client’s safety threat.
• Distractibility: The client appears distracted at times (e.g., during dressing), but distractibility alone does not account for the risk of self-harm. It contributes to disorganization but is not the main safety concern.