A nurse enters a client's room and finds the client experiencing respiratory distress. Place the following interventions in the order in which the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A. "Discarding worksheets containing client information in a wastebasket." Client information should be disposed of properly to prevent unauthorized access. Documents containing protected health information should be shredded or placed in designated confidential disposal bins rather than a regular wastebasket.
B. "Writing a client's diagnosis on the message board in the client's room." Publicly displaying a client’s diagnosis can lead to unauthorized disclosure of protected health information. While message boards can be used for general reminders such as scheduled tests, they should not include sensitive medical details.
C. "Discussing a client's prognosis with an assistive personnel who is caring for the client." While assistive personnel may need to know some aspects of a client’s care, discussing a prognosis typically falls outside their scope of practice and should be limited to appropriate healthcare professionals involved in decision-making.
D. "Giving change-of-shift report to a nurse outside the client's room." Conducting shift reports in a private or semi-private setting with only authorized personnel helps protect client confidentiality. While reports may sometimes occur at the bedside for continuity of care, they should be done in a way that minimizes exposure of personal health information to others who are not directly involved in the client's care.

Rationale for Correct Choices:

Chorioamnionitis is a bacterial infection of the amniotic fluid and fetal membranes, which can develop when the protective barrier is compromised due to prolonged rupture of membranes. This client reported clear fluid discharge the previous evening, indicating that the membranes have been ruptured for an extended period. The risk of infection increases significantly as time progresses. Additionally, the client exhibits signs of maternal restlessness and increased fetal heart rate, which could indicate an early response to infection or fetal distress.

Hemorrhage is a significant risk during labor, especially as the cervix approaches full dilation and the client exhibits increasing amounts of blood-tinged vaginal discharge. The client’s history of previous pregnancy loss and current cervical changes suggest that monitoring for postpartum hemorrhage will be essential, particularly after delivery.

Rationale for Incorrect Choices:

Disseminated intravascular coagulopathy is a severe complication associated with conditions such as placental abruption, preeclampsia, or amniotic fluid embolism. However, this client does not exhibit hallmark signs such as widespread bruising, uncontrolled bleeding, or abnormal clotting, making this a less likely immediate risk.

Seizures are characteristic of eclampsia, which is typically preceded by severe preeclampsia. While the client is restless and experiencing significant pain, there are no findings of hypertension, hyperreflexia, or neurological disturbances such as visual changes or altered mental status, making seizures an unlikely concern at this time.

Preeclampsia is a hypertensive disorder of pregnancy characterized by elevated blood pressure, proteinuria, and systemic symptoms. This client has stable blood pressure readings within the normal range, no evidence of proteinuria, and no indications of significant organ dysfunction, making preeclampsia an unlikely concern.

Dehydration is a potential concern due to the client’s nausea, vomiting, and lack of recent oral intake. However, there are no immediate signs of hemodynamic instability, such as hypotension or tachycardia, suggesting that dehydration is not the most pressing concern at this moment.