A nurse is admitting a client who is to undergo paracentesis for removal of ascitic fluid. Which of the following actions should the nurse take?

A. Frequent nosebleeds: While epistaxis can occur in some conditions affecting coagulation or blood pressure, it is not a characteristic finding in infants with coarctation of the aorta.

B. Increased intracranial pressure: Increased intracranial pressure is not a typical manifestation of coarctation of the aorta in infants. Neurologic symptoms are uncommon unless severe hypertension develops over time.

C. Upper extremity hypotension: Coarctation of the aorta usually results in hypertension in the upper extremities due to the obstruction distal to the aortic arch, not hypotension.

D. Weak femoral pulses: Weak or absent femoral pulses are an expected finding in coarctation of the aorta. The narrowing of the aorta obstructs blood flow to the lower extremities, leading to diminished pulses and lower blood pressure in the legs compared with the arms.

Rationale for correct choices

• Client reports lower back pain as 0 on a scale from 0 to 10: Resolution of back pain suggests that uterine contractions and associated discomfort have decreased, indicating reduced preterm labor activity and improved comfort. Pain control and labor suppression interventions appear effective.

• No further reports of burning with urination: The absence of dysuria indicates that a possible urinary tract infection is improving, either spontaneously or following interventions such as increased hydration or antibiotic therapy. Symptom resolution reflects clinical improvement.

• No uterine contractions noted: The absence of contractions indicates that preterm labor activity has decreased. This reflects effective management and a positive trend in preventing progression to preterm birth.

• Temperature 37.1° C (98.7° F): A normalized temperature reflects a reduction in maternal infection or inflammatory response. This indicates that the client’s fever is resolving, decreasing risk for maternal and fetal complications.

• No reports of vaginal discharge: The absence of abnormal vaginal discharge suggests that cervical or infection-related changes are resolving, reflecting decreased risk of preterm labor progression

• WBC count 12,000/mm³: The white blood cell count has decreased from the initial 16,000/mm³, showing a positive response to antibiotic therapy. A decrease from the previous elevated WBC count indicates that infection or inflammation is resolving, demonstrating laboratory improvement and decreased maternal risk.

Rationale for incorrect choices

• FHR baseline 138/min, minimal variability: A baseline fetal heart rate within normal limits is reassuring, but minimal variability persists, indicating continued need for monitoring. This alone does not indicate full clinical improvement.