A nurse is assisting with the care of a client who has pneumonia.

Exhibits

For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.

A. Beneficence. Beneficence refers to the ethical obligation to promote the well-being of clients and take actions that benefit them. While providing medication education supports the client's health, the primary ethical principle demonstrated in truthfully explaining adverse effects is veracity, not beneficence.
B. Justice. Justice involves fairness in the distribution of resources, treatment, and care. It ensures that all clients receive equitable care regardless of personal or socioeconomic differences. While justice is a fundamental ethical principle, it does not directly relate to truthfulness in medication education.
C. Veracity. Veracity is the ethical principle of honesty and truthfulness in communication with clients. By truthfully informing the client about the adverse effects of their prescribed medications, the nurse upholds veracity, ensuring the client has accurate information for informed decision-making.
D. Autonomy. Autonomy refers to the client’s right to make informed decisions about their care. While providing truthful information supports autonomy, the ethical concept the nurse demonstrates in this scenario is veracity, as the focus is on truthfully sharing medication information.

A. Report of weight change. A slight weight loss near term is a common finding as the body prepares for labor. This is not an immediate concern.
B. Client heart rate. The heart rate increased from 90/min at 0830 to 110/min at 0845. A rising maternal heart rate could indicate dehydration, pain, or early signs of infection.
C. Deep tendon reflexes. Reflexes are documented as 2+, which is within the expected range and does not indicate hyperreflexia or hyporeflexia.
D. Fetal heart rate. The FHR at 1530 is 120/min with late decelerations, which is concerning. Late decelerations suggest uteroplacental insufficiency, requiring further assessment and possible interventions such as maternal repositioning, oxygen administration, or fluid bolus.
E. Pain rating. The client reports severe back pain rated as 10/10, which may indicate fetal malposition (such as occiput posterior positioning) or rapid labor progression, both requiring evaluation and possible intervention.
F. Oxygen saturation level. The oxygen saturation has remained stable between 96% and 97%, which is within the expected range and does not require immediate intervention.
G. Report of vaginal discharge. An increased amount of blood-tinged discharge at 1530 may indicate cervical dilation or potential complications such as placental abruption, especially in the presence of late decelerations.