A nurse in an outpatient clinic is assessing a client who is pregnant for unsafe behaviors during pregnancy. Which of the following findings indicates a need for further evaluation?

Rationale:

A. Clamp the chest tube every 2 hr to assess the amount of drainage: Clamping a chest tube is not routine and can lead to tension pneumothorax by preventing air or fluid from escaping the pleural space. It should only be done briefly and under specific provider direction.

B. Add water to the water seal chamber as it evaporates: Water in the water seal chamber may evaporate over time and should be maintained at the prescribed level to preserve the one-way seal. This ensures proper functioning of the chest drainage system.

C. Mark the drainage output on the collection chamber: Marking the drainage level at regular intervals allows for accurate monitoring of output trends, which can help detect complications like hemorrhage or increased fluid accumulation.

D. Maintain the collection chamber above the level of the client's waist: The collection chamber should be kept below the level of the chest to promote gravity drainage. Elevating it above the waist can allow fluid or air to flow back into the pleural space.

E. Strip the chest tube vigorously to dislodge blood clots: Stripping is not recommended as it creates high negative pressure that may damage lung tissue. If clots are suspected, milking the tube gently or other interventions should be discussed with the provider.

Rationale:

A. Provide a quiet environment for the client: Minimizing noise and stimulation helps reduce stress and prevents spikes in intracranial pressure (ICP). A calm environment is essential for neurologically compromised clients.

B. Encourage the client to cough and deep breathe: Coughing can increase thoracic pressure and, consequently, ICP. In clients with elevated ICP, activities that increase intrathoracic or intra-abdominal pressure should be avoided to prevent worsening brain injury.

C. Obtain client vital signs every 8 hr: Clients with increased ICP require frequent monitoring, often hourly or every 2–4 hours, to detect changes in neurologic status or signs of Cushing's triad. Every 8 hours is insufficient for early intervention.

D. Maintain the head of the bed at a 30 degree angle: Elevating the head promotes venous outflow from the brain without compromising perfusion. A 30-degree elevation is a commonly recommended position to help control ICP levels.

E. Administer stool softeners to the client: Straining during bowel movements increases intra-abdominal pressure and can elevate ICP. Stool softeners reduce this risk and are a supportive intervention in the management of increased ICP.