A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis.
Which of the following actions should the nurse take?

The correct answer is choice A, B, D, and F.

Choice A rationale:

The presence of protein in the urine (proteinuria) is a sign of potential prenatal complication. Normally, urine should be protein negative. Proteinuria can be a sign of preeclampsia, a serious condition that includes high blood pressure and swelling, and can lead to preterm birth or other serious complications if not managed.

Choice B rationale:

The client’s blood pressure is 162/112 mm Hg, which is significantly higher than the normal range (less than 120/80 mm Hg). High blood pressure during pregnancy could indicate preeclampsia or other complications.

Choice C rationale:

The client’s respiratory rate is 16/min, which falls within the normal range (12-20 breaths per minute). Therefore, it does not indicate a potential prenatal complication.

Choice D rationale:

The client’s report of a severe headache unrelieved by acetaminophen is concerning. This could be a symptom of preeclampsia or other serious conditions and should be investigated further.

Choice E rationale:

The client’s gravida/parity (G3 P2 with one preterm birth) does not directly indicate a potential prenatal complication. However, a history of preterm birth could put the client at higher risk for another preterm birth.

Choice F rationale:

The client’s report of decreased fetal movement is concerning. Decreased fetal movement can be a sign of fetal distress or other complications and should be investigated further.

Choice G rationale:

The client’s urine does not contain ketones, which would indicate that the body is using fat for energy instead of glucose. This could occur in cases of poor nutrition or gestational diabetes. Since the urine is ketone negative, this does not indicate a potential prenatal complication.

The correct answer is B.

Choice A reason: Avoid preparing medications for more than two clients at one time is a guideline aimed at reducing the risk of medication errors. However, it is not an absolute rule and may vary depending on the setting and resources available.

Choice B reason: Inform clients about the action of each medication prior to administration. This practice is essential for patient education, ensuring that patients are informed about what medications they are taking and why, which can improve adherence and outcomes.

Choice C reason: Reading medication labels at least two times prior to administration is a good practice to avoid errors, but it is not always specified as a standard requirement in medication administration guidelines.

Choice D reason: Completing an incident report if a client vomits after taking a medication is necessary only if the vomiting is related to an adverse drug reaction or a medication error, not for routine vomiting.