28. A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps) (ORDERED RESPONSE)

Rationale for Correct Options:

• Placental abruption: This condition involves the premature detachment of the placenta from the uterine wall, often triggered by hypertensive disorders. The client’s elevated blood pressure (148/94 mm Hg), facial edema, and hyperreflexia point toward preeclampsia, a leading risk factor for placental abruption.
• Hypertension: Hypertension during pregnancy compromises uteroplacental blood flow, potentially causing vascular damage and leading to placental separation. The client’s reading reflects stage 1 hypertension, which, along with other signs, raises concern for placental complications such as abruption.

Rationale for Incorrect Options:

• Spontaneous abortion: Typically occurs before 20 weeks gestation, making it irrelevant for a client at 30 weeks. There are no signs of fetal loss or cervical dilation in this case.
• Placenta previa: Presents with painless vaginal bleeding in the second or third trimester. This client has no vaginal bleeding or placental misplacement.
• Chorioamnionitis: This infection would present with fever, uterine tenderness, and fetal tachycardia. The client is afebrile, has clear lung sounds, and shows no evidence of intrauterine infection.
• Oligohydramnios: Usually detected via ultrasound or significantly low fundal height. The client's fundal measurement (29 cm at 30 weeks) is appropriate, and there’s no mention of decreased amniotic fluid.
• Hyperreflexia: Although suggestive of preeclampsia, it is a secondary symptom that indicates neurologic involvement and seizure risk rather than directly causing placental abruption.
• Vomiting: While it may be associated with preeclampsia, it is non-specific and does not independently increase the risk of placental abruption without supporting findings like hypertension or abdominal pain.

A. Review the facility policy about the use of an interpreter: Reviewing the policy ensures compliance with institutional and legal standards for providing language services, helping the nurse arrange an appropriate and qualified interpreter.
B. Request an interpreter of a different gender from the client: Gender preferences may vary by culture, but requesting a different-gender interpreter without considering the client's preferences may cause discomfort or miscommunication.
C. Direct attention toward the interpreter when speaking to the client: The nurse should maintain eye contact and speak directly to the client to foster trust and communication, rather than addressing the interpreter.
D. Request a family member or friend to interpret information for the client: Using untrained individuals may lead to misinterpretation, violate confidentiality, and is discouraged except in emergencies when no professional is available.