A nurse is assisting with the care of a client.

Exhibits

For each data collection finding, dick to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

A. Asking the client to point their toes before applying the stockings is an appropriate action. This maneuver helps to flex the foot, making it easier to apply the stockings and ensuring they fit properly without causing discomfort.
B. Turning the stockings inside out before applying them is an acceptable practice as it can make them easier to put on and ensure they fit well on the client’s leg. This action does not require intervention.
C. Ensuring that creases in the stockings are on the front of the client's legs requires intervention. The stockings should be applied smoothly and without creases to prevent pressure areas, which could lead to skin breakdown or complications. Creases should be avoided on any part of the stockings that may cause discomfort or impede circulation.
D. Applying the stockings before the client gets out of bed is appropriate. Antiembolic stockings are often applied while the client is in bed to prevent complications associated with immobility, such as deep vein thrombosis (DVT). This action supports patient safety and comfort.

Anticipated:

• Administer oxygen at 10 L/min via non-rebreather face mask as needed: The client has late decelerations, indicating possible fetal hypoxia. Providing supplemental oxygen can enhance placental oxygenation and improve fetal status.
• Position the client in lateral side-lying position: This position improves uteroplacental perfusion by relieving compression of the inferior vena cava, which can help resolve late decelerations and improve fetal oxygenation.
• Encourage the client to void every 2 hr: A full bladder can impede fetal descent and contribute to labor discomfort. Regular voiding helps prevent bladder distention and promotes labor progress.
• Administer prophylactic IV antibiotic: The client is positive for Group B streptococcus (GBS), which necessitates prophylactic antibiotic administration during labor to reduce the risk of neonatal infection.
• Evaluate the client for uterine tachysystole: The client's contractions have increased in frequency and intensity. Assessing for excessive uterine activity is critical to prevent fetal distress and complications such as uterine rupture.

Contraindicated:

• Administer magnesium sulfate IV: Magnesium sulfate is used for seizure prophylaxis in preeclampsia or for tocolysis in preterm labor. The client does not have preeclampsia, and labor is at term, making this intervention unnecessary.