A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take?

The correct answers are Choices A and C.

Choice A rationale: Severe hypertension in pregnancy disrupts placental perfusion and vascular integrity, increasing risk of placental abruption due to premature separation and hemorrhage, threatening both maternal and fetal outcomes.

Choice B rationale: Cervical insufficiency is linked to structural weakness or trauma, not hypertension; it typically presents with painless dilation and is unrelated to elevated blood pressure or vascular compromise.

Choice C rationale: Hypertensive encephalopathy and preeclampsia can progress to eclampsia, marked by seizures. Elevated BP increases cerebral edema and excitability, triggering convulsions if unmanaged.

Choice D rationale: Hypoglycemia is not a direct consequence of hypertension; it’s more associated with insulin dysregulation, poor intake, or medication effects, not elevated blood pressure.

Choice E rationale: Heart failure may occur in chronic hypertension but is less acute than seizure or abruption risk in this context. No signs of fluid overload or cardiac decompensation are present in the vitals.

The correct answer is Choice a.

Choice a rationale: The nurse should obtain the specimen immediately upon the client waking up, as sputum from deep in the lungs is usually more easily collected at this time. Sputum collected upon waking up is more likely to contain secretions from the lower respiratory tract, providing a better sample for tuberculosis diagnosis. This timing maximizes the chance of detecting the bacteria.

Choice b rationale: Choice b is incorrect because the typical volume of sputum needed for testing is about 1 teaspoon (5 mL), not 15 to 20 mL. Collecting such a large volume could be challenging for the client and unnecessary for diagnostic purposes.

Choice c rationale: Choice c is incorrect because while gloves should be worn, they do not need to be sterile, just clean. The use of clean gloves is sufficient to prevent contamination during specimen collection, and sterile gloves are not required for this procedure.

Choice d rationale: Choice d is incorrect because it’s important to try to collect the specimen as soon as possible, not wait a full day. Delaying collection for a day could result in a missed opportunity to diagnose tuberculosis and initiate appropriate treatment promptly. Collecting the specimen promptly maximizes the accuracy of diagnostic testing and facilitates timely intervention for the client's health.