A home health nurse is caring for a client who has terminal cancer. The client tells the nurse they wish to stop their chemotherapy treatments. Which of the following statements should the nurse make?

Rationale:
A. Fundal height: The fundus has descended to 4 cm below the umbilicus and remains firm, indicating effective involution of the uterus and improvement from the previously boggy, tender fundus.

B. Heart rate: The client’s heart rate has decreased from 110/min on postpartum day 3 to 88/min on day 5, reflecting stabilization and decreased physiologic stress.

C. Hgb: Hemoglobin decreased slightly from 11.1 g/dL to 10 g/dL. While this is a minor drop, it does not indicate improvement and may reflect ongoing blood loss or hemodilution postpartum.

D. Temperature: The client’s temperature has normalized to 37.2° C (99° F) from febrile readings of 38.6° C (101.5° F), indicating resolution of the infection or inflammatory process.

E. WBC count: The WBC count decreased from 33,000/mm³ to 10,000/mm³, demonstrating resolution of the previous leukocytosis associated with infection or postpartum inflammation.

F. Lochia: Lochia has decreased in amount, is brownish-red without odor, indicating normal postpartum progression and resolution of the previously foul-smelling discharge, signifying improvement.

Rationale for Correct Choices

• Evaluating the fetal heart rate tracing: The client presents with severe preeclampsia, as indicated by hypertension (166/110 mm Hg), 3+ proteinuria, and hyperreflexia. The priority is to assess fetal well-being since decreased fetal movement and maternal hypertension can compromise placental perfusion, placing the fetus at risk for hypoxia or distress.

• Administering magnesium sulfate IV: Once fetal assessment confirms stability, magnesium sulfate should be initiated to prevent eclamptic seizures. This medication stabilizes the central nervous system by reducing neuromuscular excitability and cerebral irritation associated with severe preeclampsia.

Rationale for Incorrect Choices

• Administering acetaminophen PO: The client already reported that acetaminophen was ineffective for headache relief. The headache is a sign of severe preeclampsia, not a benign pain complaint, so administering more acetaminophen does not address the underlying pathology.

• Obtaining 24-hour urine collection: While important for confirming the degree of proteinuria, this action is not an immediate priority. Stabilizing maternal and fetal conditions takes precedence over diagnostic collection.

• Inserting an indwelling urinary catheter: The catheter is required for strict intake and output monitoring during magnesium therapy, but it is not performed before ensuring fetal stability and initiating seizure prophylaxis.

• Administering betamethasone IM: Betamethasone promotes fetal lung maturity, which is appropriate in preterm conditions; however, it is not the immediate priority. Seizure prevention and fetal assessment are more urgent interventions at this stage.