A nurse is assisting with the care of a client who needs an interpreter. Which of the following actions should the nurse take?

Rationale:

A. 2+ pitting edema of the lower extremities: Mild to moderate lower extremity edema is common in pregnancy and often seen in preeclampsia. While it should be monitored, it is not an immediate danger unless accompanied by other severe symptoms.

B. Increased hemoglobin: Hemoconcentration may occur in preeclampsia due to fluid shifting into interstitial spaces, but a mildly elevated hemoglobin alone does not warrant urgent intervention. It should be evaluated in the context of other lab and clinical findings.

C. Blood pressure 158/54 mm Hg: Although the systolic pressure is elevated, it does not meet the threshold of severe hypertension (>160 systolic or >110 diastolic). This finding warrants monitoring and documentation but is not the most urgent among the listed options.

D. Client report of upper right quadrant pain: Right upper quadrant or epigastric pain can signal liver involvement in severe preeclampsia, potentially indicating HELLP syndrome. This is a critical warning sign and requires immediate attention to prevent complications such as liver rupture or seizure.

Rationale:

A. "We've seen steady improvement in other clients who are depressed.": While this may sound reassuring, it provides generalized information that may create unrealistic expectations. It does not address the partner’s specific concerns or open up a dialogue for emotional support or understanding.

B. "Tell me what you know about depression,": This response encourages open communication and assesses the partner's understanding of the condition. It allows the nurse to provide accurate, individualized information and emotional support based on what the partner already knows or believes.

C. "No one really knows the answer to that question.": Though factually true, this statement may seem dismissive or lacking empathy. It does not invite discussion or support the emotional needs of the partner, who is likely feeling uncertain or overwhelmed.

D. "The important thing is that he gets better, not how long it takes.": This response minimizes the partner’s valid concern about recovery time. It may come across as invalidating and does not provide helpful or therapeutic communication.