A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?

Rationale:

A. Close all nearby windows and doors: Containment helps prevent the spread of smoke and flames. Closing doors and windows minimizes oxygen supply to the fire and keeps it from moving into other areas.

B. Use the unit's fire extinguisher to attempt to put out the fire: The final step is to extinguish the fire, but only if it is safe to do so. The nurse should not attempt this before ensuring safety, alerting others, and containing the fire.

C. Transport the client to another area of the nursing unit: The first priority in a fire situation is rescue, removing anyone in immediate danger, especially vulnerable clients who cannot evacuate themselves.

D. Activate the facility's fire alarm system: Once the client is safe, the next step is to alarm the system to alert others in the facility and begin emergency response protocols.

Rationale:

A. Initiate contact precautions: No signs of infection or communicable disease are present, so contact precautions are unnecessary.

B. Decrease lighting in the client’s room: The client is restless and later becomes lethargic, suggesting neurological irritability or worsening preeclampsia. Reducing environmental stimuli like lighting can help minimize seizures and agitation.

C. Check urinary output: The client’s urine output decreased to 20 mL in one hour, which is concerning for renal impairment often seen in severe preeclampsia. Monitoring output closely helps detect worsening kidney function and fluid balance.

D. Prepare for amniocentesis: There is no indication for amniocentesis in this clinical scenario related to preeclampsia or maternal condition.

E. Encourage bed rest: Bed rest in the side-lying position improves uteroplacental perfusion and helps control blood pressure, reducing the risk of complications from preeclampsia.

F. Monitor blood pressure: Blood pressure is elevated and critical to assess frequently to evaluate disease progression and prevent hypertensive emergencies or seizures.

G. Apply internal fetal monitor: The client has no contractions and a stable external fetal heart rate. Internal monitoring is invasive and reserved for active labor or when external monitoring is insufficient.

H. Assess DTR: The shift from hyperreflexia (3+) to hyporeflexia (1+) may indicate worsening neurological status or magnesium sulfate toxicity if administered. Continuous monitoring is essential.