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, C, D, E, F, and G.

Choice A rationale: Antihypertensive medication is indicated due to sustained elevated BP (≥160/110 mm Hg), which increases risk for stroke, placental abruption, and eclampsia. Prompt control reduces maternal and fetal morbidity.

Choice B rationale: Routine vaginal exams are contraindicated unless signs of labor are present. Frequent exams increase infection risk and are not part of standard care for hypertensive or preeclamptic clients.

Choice C rationale: A low-stimulation environment (dim lights, quiet room) reduces CNS irritability and seizure risk in preeclampsia. It supports neuroprotection and aligns with seizure precaution protocols.

Choice D rationale: Betamethasone promotes fetal lung maturity in preterm gestation when delivery is likely. It reduces neonatal respiratory distress syndrome and improves outcomes in hypertensive pregnancies.

Choice E rationale: A 24-hour urine specimen quantifies proteinuria, essential for diagnosing preeclampsia severity. Protein 3+ on dipstick warrants confirmation via timed collection for accurate staging.

Choice F rationale: Hourly intake and output monitoring detects fluid shifts, renal compromise, and early signs of pulmonary edema. It’s critical in hypertensive disorders to guide fluid management.

Choice G rationale: Bed rest minimizes physical stress, stabilizes BP, and reduces risk of placental disruption. Left lateral positioning enhances uteroplacental perfusion and supports fetal oxygenation.

Choice A rationale:

Metallic taste in mouth. Metallic taste in the mouth is a common side effect of many medications, including sertraline. It occurs due to the medication's effect on taste receptors. Patients should be informed about this side effect, but it is not a serious adverse effect that requires immediate medical attention.

Choice B rationale:

Increased urinary frequency. Increased urinary frequency is not a commonly reported side effect of sertraline. While some individuals may experience changes in urination patterns, it is not a significant adverse effect associated with this medication.

Choice C rationale:

Dry cough. Dry cough is not a known side effect of sertraline. Cough can occur due to various reasons, such as allergies, respiratory infections, or other medications, but it is not directly caused by sertraline.

Choice D rationale:

Excessive sweating. Excessive sweating, also known as hyperhidrosis, is a potential adverse effect of sertraline. It can be bothersome for some individuals and may impact their quality of life. Patients should be aware of this side effect and report it to their healthcare provider if it becomes bothersome or persistent.