A nurse in an emergency department is assessing four clients. Which of the following clients should the nurse see first?

Rationale:

A. "Surprise your son with a new bedroom after you bring the baby home.": Sudden changes, especially without preparation, can increase feelings of insecurity or jealousy in young children. Involving the child in changes before the baby arrives helps promote acceptance and reduces anxiety.

B. "Purchase a gift to give to your son from your baby.": This strategy helps foster a positive bond between the older sibling and the newborn. It helps the child feel acknowledged and valued during a time when attention naturally shifts to the new baby.

C. "Make sure you are holding your baby when your son comes to visit you in the hospital.": Holding the baby during the first meeting can intensify feelings of displacement or jealousy in the older child. It's better to greet the child warmly and introduce the baby together to maintain emotional connection.

D. "Use medical terminology when teaching your son about your new baby.": Preschool-aged children benefit more from simple, age-appropriate explanations. Medical jargon can confuse or overwhelm them, making it harder to process the concept of a new sibling.

Rationale for correct choices:

• Blood pressure: A reading of 148/94 mm Hg is elevated and meets criteria for gestational hypertension, especially in a client who is gravida 1 para 0. It raises concern for preeclampsia and must be closely monitored, particularly with concurrent symptoms like headache and edema.
• DTR: A deep tendon reflex of 3+ is considered hyperreflexic and may signal increased central nervous system irritability. In the setting of elevated blood pressure and other preeclampsia signs, it raises concern for worsening severity or impending seizure activity.
• Lower extremity assessment: The presence of 1+ dependent edema can be a normal pregnancy finding, but when paired with facial swelling, recent weight gain, and elevated blood pressure, it becomes significant and suggests fluid retention associated with preeclampsia.
• Weight assessment: A gain of 0.68 kg (1.5 lb) in a week may seem modest, but when it is sudden and combined with facial and dependent edema, it can indicate abnormal fluid accumulation. This pattern is concerning for preeclampsia and requires follow-up.
• Nausea: While nausea is common in pregnancy, its presence along with right upper quadrant pain and headache raises red flags for severe preeclampsia or HELLP syndrome. These are warning signs of potential hepatic involvement or worsening disease.

Rationale for incorrect choices:

• Fundal height: A fundal height of 29 cm is consistent with gestational age around 29 weeks and does not indicate an abnormal finding in this context. No follow-up is needed unless measurements are inconsistent with gestational dating.
• Respiratory assessment: The client’s lungs are clear to auscultation and respirations are even and non-labored. Oxygen saturation is 95% on room air, which is within normal range during pregnancy, so no respiratory issues require intervention.
• Fetal heart tracing: A fetal heart rate of 140/min is within the normal range of 110–160 beats per minute. There are no reported decelerations or signs of distress, so no immediate follow-up is indicated for the fetal tracing.