A nurse is assisting with the admission of a client to the labor and delivery unit.

Exhibits

Which of the following actions should the nurse recommend including in the client's plan of care? For each potential recommendation, click to specify if the recommendation is anticipated or contraindicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

A. An advanced practice nurse, such as a nurse practitioner or clinical nurse specialist, has the training to assess medication interactions and adjust prescriptions if necessary. They can evaluate the client's medications, consider potential adverse effects, and collaborate with the prescribing provider. Consulting an advanced practice nurse ensures safe and effective medication management.
B. A psychologist focuses on mental health assessment and therapy but does not prescribe or manage medications. They may help clients cope with medication-related concerns, but they lack the authority to assess or modify prescriptions. Medication-related inquiries should be directed to a medical provider or pharmacist.
C. A social worker assists clients with psychosocial needs, financial concerns, and community resources but does not have the expertise to evaluate medication interactions. They can provide support for medication access or adherence issues but not clinical medication guidance. Medication safety requires consultation with a qualified medical professional.
D. A patient care technician provides basic client care, such as vital sign monitoring and assisting with activities of daily living. They do not have the training to assess medication interactions or provide pharmacological advice. Medication concerns should be referred to a licensed healthcare provider.

• Administer sublingual nitroglycerin. Nitroglycerin is a first-line treatment for angina or suspected myocardial infarction. It dilates coronary arteries, improving blood flow and reducing myocardial oxygen demand.
• Apply supplemental oxygen. Routine oxygen administration is no longer recommended unless the client is hypoxic (oxygen saturation below 90%) because excessive oxygen can lead to vasoconstriction and worsen myocardial injury.
• Obtain a 12-lead ECG. While an ECG is important for diagnosing myocardial infarction, the priority in an acute chest pain episode is symptom relief and hemodynamic stability. The ECG should already have been obtained at admission.
• Administer morphine sulfate IV. Morphine is used to manage severe chest pain that is not relieved by nitroglycerin. It reduces myocardial oxygen demand, preload, and anxiety, which can help relieve symptoms.
• Monitor vital signs. Continuous monitoring is essential, but it is not the most immediate intervention in an acute episode of worsening chest pain. The focus should be on relieving ischemia and reducing myocardial workload.
• Educate the client about smoking cessation. While smoking cessation is critical for long-term cardiovascular health, education is not a priority when the client is experiencing acute chest pain requiring immediate intervention.