The nurse is continuing to assist with the care of the client.

Nurses' Notes.

0900: 0930: Client is at 31 weeks of gestation and presents with a severe headache unrelieved by acetaminophen.

Client also reports urinary frequency and decreased fetal movement.

Client is a. gravida 3, para 2 with one preterm birth.

Client reports a constant and throbbing headache and rates their pain as a 6 on a scale of 0 to 10.

Denies visual disturbances.

+3 pitting edema in bilateral lower extremities.

Patellar reflex 4+ without the presence of clonus.

Client reports occasional nighttime leg cramps.

Reports 3 fetal movements within the last 30 min.

External fetal monitor applied with a. baseline FHR 140/min with occasional accelerations and moderate variability.

No uterine contractions noted.

The nurse is reviewing the findings.

For each finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome.

Each finding may support more than one disease process.

The correct answer is ChoiceC.

Choice A rationale:Restricting fluid intake to 1 L per day is not recommended for a client with a urinary tract infection (UTI). Adequate hydration is essential for flushing out bacteria from the urinary tract and preventing further infections. Therefore, this choice is incorrect.

Choice B rationale:Taking the prescribed antibiotic until manifestations are gone is partially correct. It’s crucial for the client to complete the entire course of antibiotics, even if symptoms improve or disappear before the medication is finished. Stopping antibiotics early can lead to recurrent infections or antibiotic resistance. Therefore, this choice ispartially correct, but the instruction should be clarified to ensure the client understands the importance of completing the full course of antibiotics.

Choice C rationale:Wearing cotton underwear is recommended for clients with a UTI. Cotton is a breathable fabric that can help keep the area around the urethra dry, reducing the likelihood of bacterial growth. Therefore, this choice is correct.

Choice D rationale:Drinking orange juice daily for 3 to 4 weeks is not specifically recommended for a client with a UTI. While vitamin C can help inhibit bacterial growth, orange juice is high in sugar, which can promote bacterial growth. It’s more beneficial to drink water and other unsweetened fluids to help flush out the bacteria from the urinary tract. Therefore, this choice is incorrect.

Choice A rationale:

Pedal pulses are a measure of peripheral circulation. A 2+ rating is considered normal, indicating a brisk, expected response. There’s no change in the client’s pedal pulses from Day 1 to Day 5, so this doesn’t require immediate follow-up.

Choice B rationale:

Oxygen saturation is not mentioned in the Nurses’ Notes, so we cannot provide a rationale for this choice.

Choice C rationale:

Breath sounds are an important indicator of respiratory health. The client’s breath sounds are clear and present throughout on both Day 1 and Day 5, which is normal and doesn’t require immediate follow-up.

Choice D rationale:

Respiratory rate is not mentioned in the Nurses’ Notes, but any significant change in respiratory rate could indicate a problem such as infection or pain, and would require immediate follow-up.

Choice E rationale:

The abdominal dressing shows a large amount of serosanguinous drainage on Day 5, compared to a small amount on Day 1. This could indicate a complication such as infection or dehiscence (separation of the wound), especially since the client reported feeling something “popped” at the incision site after coughing. This requires immediate follow-up.

Choice F rationale:

Heart rate is not mentioned in the Nurses’ Notes, but any significant change in heart rate could indicate a systemic response to factors such as pain or infection, and would require immediate follow-up. In summary, while pedal pulses and breath sounds remain normal, the change in the abdominal dressing and potential changes in respiratory rate and heart rate (though not documented here) should be addressed immediately to ensure the client’s health and recovery.