A nurse in an acute care mental health facility is participating in a medication education group. The leader of the group uses a laissez-faire leadership style. Which of the following actions should the nurse expect from the leader during the session?

1. Perform suctioning

Contraindicated

Suctioning can be a stressor to the body, and in patients with autonomic dysreflexia, it could potentially exacerbate the condition and lead to further increases in blood pressure. In autonomic dysreflexia, managing the underlying trigger (such as a full bladder or bowel impaction) is key, not suctioning unless there is a specific need related to respiratory issues. This action could make the elevated blood pressure worse.
2. Withhold pain medication for headache until other manifestations resolve

Contraindicated
Pain management is critical in a patient with autonomic dysreflexia. The headache is a significant symptom of autonomic dysreflexia and needs to be addressed immediately, as pain is often the trigger. Withholding pain medication could worsen the client's symptoms and contribute to further complications. Proper management of pain should occur concurrently with interventions to address the elevated blood pressure.
3. Assess blood pressure every 15 minutes

Anticipated
Monitoring blood pressure is crucial in patients with autonomic dysreflexia to track changes and assess for improvement or worsening of hypertension. The nurse should frequently assess the client’s blood pressure to ensure it is returning to normal after appropriate interventions are initiated. Autonomic dysreflexia requires continuous monitoring of blood pressure to avoid complications such as stroke or cardiac events.
4. Administer nifedipine

Contraindicated
While nifedipine (a calcium channel blocker) is used to manage hypertension, it is not typically recommended as a first-line treatment for autonomic dysreflexia in spinal cord injury patients. Instead, interventions should focus on removing the triggering stimulus (e.g., bladder distension, constipation, or pressure ulcers). If blood pressure does not respond, other medications such as nitroglycerin or hydralazine may be used, but nifedipine is not the preferred option.
5. Assess for urinary retention

Anticipated
Urinary retention is a common trigger for autonomic dysreflexia in patients with spinal cord injuries, particularly those with injuries at or above T6. If the client is experiencing symptoms of autonomic dysreflexia, one of the first steps is to assess for urinary retention. If the bladder is full, catheterization may be required to relieve the pressure and help normalize the blood pressure. The nurse should assess the client’s urinary status promptly.
6. Place client in supine position

Contraindicated
In the case of autonomic dysreflexia, placing the client in a supine position could potentially worsen the elevated blood pressure by increasing venous return and making it harder for the body to normalize blood pressure. The client should be positioned sitting upright or at a 45-degree angle, which can help lower blood pressure by promoting venous pooling and reducing the effects of the autonomic dysreflexia response.

Rationale
1. History and Physical
Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks
The client's history of a preterm birth at 30 weeks in a previous pregnancy is a significant risk factor for preterm labor in the current pregnancy. A history of preterm labor increases the likelihood of recurrence, and close monitoring is essential. This information alone does not require immediate follow- up but is important in guiding the overall care plan and risk assessment for preterm labor.
2. Nurses' Notes
Lower back pain and pinkish vaginal discharge.
Lower back pain and pinkish vaginal discharge are common symptoms of preterm labor. The pinkish vaginal discharge could indicate bloody show, which is sometimes seen with cervical dilation or preterm labor.
Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
Regular uterine contractions (every 8 minutes) in a client at 33 weeks gestation could indicate preterm labor. Contractions every 8 minutes with strong palpation and 30-second duration should be further assessed for their frequency, intensity, and impact on cervical dilation. This finding requires follow-up to determine whether these contractions are progressing to actual labor.
Minimal variability.
Minimal variability can sometimes be a sign of fetal distress or hypoxia, but it can also be seen in some normal circumstances. However, it is a finding that requires closer observation and may warrant further investigation to assess fetal well-being, especially in the context of preterm labor.
Finding: Cervical exam indicates 2 cm, 50% effaced, 0 station.
The cervix is 2 cm dilated, 50% effaced, and at a station of 0. This indicates that the cervix is beginning to open and efface, which is a sign of early labor. Since the client is at 33 weeks gestation, this is concerning for preterm labor, and the client should be closely monitored for further cervical changes and labor progression.