A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse, "This baby constantly cries.
My partner works all the time, and I can't take any more.”. Which of the following responses is the nurse's priority?

Choice A rationale

Respecting the client's autonomy is paramount in nursing practice. If a client explicitly states they do not want visitors, the nurse should communicate this directly to the sibling. This upholds the client's right to make decisions about their care and interactions.

Choice B rationale

While the provider may be involved in the client's overall care, directly referring the sibling regarding visitation preferences bypasses the nurse's role in communicating the client's wishes. The nurse has a responsibility to act on the client's stated preferences.

Choice C rationale

Encouraging the client to see the sibling might undermine the client's expressed wishes and feelings. The nurse should first respect the client's decision and explore the reasons behind it before suggesting a visit.

Choice D rationale

Arranging a visit in the dayroom without the client's consent disregards their autonomy and right to privacy. The client has the right to decide who they interact with and where those interactions occur.

Choice A rationale: WBC count

Clozapine carries a risk of agranulocytosis, a severe reduction in white blood cell (WBC) count that can leave the body vulnerable to infections. The client’s WBC count of 4,800/mm³ is below the normal range (5,000–10,000/mm³), raising concern for compromised immune function. Since routine monitoring of WBC is necessary for clients on clozapine, the provider should be notified to reassess whether the medication should be continued or adjusted.

Choice B rationale: Blood glucose level

While the client’s blood glucose level of 200 mg/dL is elevated, atypical antipsychotics like clozapine can contribute to metabolic syndrome and insulin resistance. However, this is not an immediate reason to clarify the prescription unless hyperglycemia is significantly worsening or causing complications.

Choice C rationale: Blood pressure

A blood pressure of 110/68 mm Hg is within normal limits and does not necessitate clarification of the prescription. Clozapine may cause hypotension in some clients, but this reading does not indicate a concerning drop in blood pressure.

Choice D rationale: Temperature

A temperature of 37.8°C (100.0°F) is slightly elevated but does not independently warrant medication clarification. However, because fever plus a low WBC count raises the suspicion of infection, the provider should be informed of both findings to assess potential complications.