A client who is 37 weeks gestation comes to the women's health clinic reporting an excruciating headache.

On examination, the nurse determines the client has an elevated blood pressure.

Which action should the nurse implement next?

Choice A rationale

In bacterial meningitis, monitoring antibiotic levels is critical during treatment to ensure therapeutic effectiveness and avoid toxicity. However, it is not necessary to check antibiotic levels after completing the course. The body clears the antibiotics within a few days, and monitoring is more relevant during therapy.

Choice B rationale

While monitoring wet diapers is important during illness, it's not necessary to continue strict monitoring post-treatment. Wet diapers track hydration and renal function, which should normalize after successful treatment.

Choice C rationale

Continuous use of antipyretics is unnecessary post-treatment. Fever management is more critical during active infection. Post-treatment, fevers should subside, making continuous medication redundant and possibly harmful.

Choice D rationale

Auditory monitoring is crucial after meningitis due to the risk of hearing loss, a common complication. Early detection of auditory issues allows for timely intervention and support for the child’s development.

Choice A rationale

A weight gain of 2 pounds (0.91 kg) in a 34-week gestation multigravida is generally considered normal. During the third trimester, it is typical for a pregnant woman to gain around 0.5 to 1 pound per week. This weight gain helps support the growing fetus and prepare the mother's body for labor and breastfeeding. However, sudden or excessive weight gain could indicate fluid retention or preeclampsia, but a 2-pound gain alone is not necessarily a concern.

Choice B rationale

1+ edema on the lower extremities is a common finding during pregnancy, especially in the later stages. It is usually due to increased blood volume and pressure on the pelvic veins from the growing uterus, which can slow the return of blood from the legs. While some degree of edema is normal, particularly in the ankles and feet, it is important to monitor for sudden or severe swelling, which could be a sign of preeclampsia.

Choice C rationale

A fundal height of 30 cm at 34 weeks gestation is concerning because it is less than the expected measurement. Fundal height typically corresponds to gestational age in centimeters (±2 cm). Therefore, at 34 weeks, the expected fundal height would be between 32 and 36 cm. A smaller fundal height could indicate intrauterine growth restriction (IUGR), oligohydramnios, or other fetal development issues, which require further evaluation by the healthcare provider.

Choice D rationale

A fetal heart rate (FHR) of 110 beats per minute (bpm) is within the normal range for a fetus. The normal FHR typically ranges from 110 to 160 bpm. Although 110 bpm is on the lower end of the normal range, it is still considered acceptable. Significant deviations from the normal range, either too low (bradycardia) or too high (tachycardia), could indicate fetal distress and require immediate attention.