A nurse in the emergency department is caring for a client.

Exhibits

The nurse reviews the client’s medical record. Select the 4 actions the nurse should take.

The first action the nurse should take isevaluating the fetal heart rate tracing,followed by administering labetalol IV.

Rationale forCorrect Answers:

Evaluating the fetal heart rate tracing first is the priority because the client is at 31 weeks of gestation with severe preeclampsia and reported decreased fetal movement. Fetal assessment is time-sensitive; identifying any signs of fetal distress is critical to prevent hypoxia or other complications.

Administering labetalol IV is the next priority to manage the client’s severe hypertension (BP 166/110 mm Hg), which places both mother and fetus at risk for complications such as stroke, placental abruption, or fetal compromise.

Rationale for Incorrect options:

Administering acetaminophen PO addresses maternal headache but does not prevent immediate maternal or fetal complications, so it is lower priority.

Obtaining a 24-hour urine collection, betamethasone, and lactated Ringer’s are important interventions but are secondary to assessing fetal status and stabilizing maternal blood pressure.

A. Vital signs: The client’s heart rate remains elevated (110–118/min) and orthostatic hypotension persists (BP 116/80 sitting, 88/68 standing), indicating ongoing dehydration and malnutrition. These findings suggest worsening fluid and electrolyte imbalance, not improvement.

B. Client statement: The client’s verbalization, “I want to stop and get better,” reflects acknowledgment of the disorder and readiness for behavioral change, a critical first step in recovery from bulimia nervosa. This statement shows therapeutic progress in the mental health aspect of treatment, demonstrating insight and motivation for recovery. In clients with eating disorders, early progress is typically seen in attitude and cooperation rather than rapid physical recovery.

C. ECG: The ECG continues to show sinus tachycardia with premature ventricular contractions (PVCs), consistent with hypokalemia and cardiac irritability. No improvement in cardiac stability is evident.

D. Electrolytes: Laboratory results show worsening hypokalemia (K⁺ 2.9 mEq/L) and hyponatremia (Na⁺ 130 mEq/L). These indicate increasing severity of electrolyte imbalance, a potentially life-threatening complication.