A nurse is assisting with the care of a client who is in labor with ruptured membranes and has herpes simplex virus with active lesions.
Which of the following actions should the nurse take?

Collaborate with the client to develop a daily physical exercise routine. This intervention can help reduce aggression and impulsivity in schizophrenia by providing an outlet for frustration, enhancing self-esteem, and improving mood. Physical exercise can also improve physical health and reduce the risk of metabolic syndrome associated with antipsychotic medications.

Choice A is wrong because warning the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination is punitive and threatening. This can increase the client’s anxiety, paranoia, and hostility, and may worsen the psychotic symptoms. Seclusion should only be used as a last resort when the client poses a serious danger to self or others, and not as a punishment or coercion.

Choice B is wrong because keeping the facility’s security personnel constantly visible to the client throughout treatment is intimidating and stigmatizing. This can also increase the client’s fear, distrust, and resentment, and may trigger aggressive behavior. Security personnel should only be involved when there is an imminent risk of violence, and not as a routine measure.

Choice D is wrong because agreeing that the hallucinations are real if the client exhibits aggressive behavior toward other clients is reinforcing the delusional belief and rewarding the aggression. This can also confuse the client and undermine the therapeutic relationship.

The nurse should acknowledge the client’s experience of hallucinations, but not endorse them as reality. The nurse should also set clear limits on aggressive behavior and use de-escalation techniques to calm the client.

Blood glucose 130 mg/dL.

This is because the normal range of blood glucose for pregnant women is 70 - 110 mg/dL .

A blood glucose level of 130 mg/dL indicates gestational diabetes, which can have adverse effects on the mother and the fetus.

The nurse should report this finding to the provider and initiate interventions such as dietary counseling, glucose monitoring, and insulin therapy if needed.

Choice A is wrong because WBC 7,000/mm³ is within the normal range for pregnant women, which is 4,500 to 10,000 cells/mcL .

A low WBC count would indicate an increased risk of infection, while a high WBC count would indicate inflammation or infection.

Choice B is wrong because hemoglobin 13 g/dL is within the normal range for pregnant women, which is 11 to 14 g/dL .

A low hemoglobin level would indicate anemia, while a high hemoglobin level would indicate dehydration or polycythemia.

Choice D is wrong because RBC 5.8 million/mm³ is within the normal range for pregnant women, which is 4.2 to 5.9 million/mm³ .

A low RBC count would indicate anemia or hemorrhage, while a high RBC count would indicate dehydration or polycythemia.