A nurse is caring for a client.

Click to highlight the findings that are contraindications to the use of a combined oral contraceptive. To deselect a finding, click on the finding again.

History and Physical

1 year ago:

33-year-old client here for routine physical examination and is requesting contraception until they attempt to conceive in about a year. Client has diabetes mellitus, diagnosed 24 years ago. Care is managed by an endocrinologist, has an insulin pump. States HbA1c was 6.7% last month. Client also has migraine headaches with aura and gastroesophageal reflux disease.

Client is a lifetime nonsmoker, reports rarely drinking alcohol. Client is a law enforcement officer and works full time. Reports exercising three or four times per week, usually walking for 2 to 3 miles or riding a stationary bike. Client had a tonsillectomy at 6 years of age. Also had a deep vein thrombosis while travelling internationally 5 years ago.

Rationale for correct choices

• Nephrotic syndrome: The child presents with periorbital edema, hypoalbuminemia, hyperlipidemia, proteinuria, and foamy dark urine, classic signs of nephrotic syndrome. The edema fluctuates during the day and laboratory values confirm protein loss. The condition is primarily due to increased glomerular permeability rather than infection or chronic renal disease.

• Encourage a low-sodium diet: A low-sodium diet helps reduce fluid retention and edema associated with hypoalbuminemia. Managing sodium intake supports blood pressure stability and decreases further renal strain. Dietary management complements pharmacologic treatment and promotes comfort by decreasing swelling.

• Administer oral corticosteroids: Corticosteroids are the first-line treatment for nephrotic syndrome, reducing proteinuria and inflammation. Timely administration can induce remission and prevent progression. Steroid therapy also helps normalize serum albumin levels, contributing to improved oncotic pressure and reduced edema.

• Abdominal girth: Monitoring abdominal girth allows early detection of ascites and worsening edema. Progressive increase in girth indicates fluid retention and guides fluid management. This parameter provides a visual and measurable indicator of the child’s response to therapy.

• Urine specific gravity: Urine specific gravity tracks protein loss and hydration status. Elevated values indicate concentrated urine due to proteinuria, which is a hallmark of nephrotic syndrome. Monitoring changes helps assess treatment efficacy and disease progression.

Rationale for incorrect choices

• Acute glomerulonephritis: Typically presents with hematuria, hypertension, and mild proteinuria, often after a recent infection. This child has massive proteinuria and hyperlipidemia, which aligns more with nephrotic syndrome. The edema pattern and labs do not support post-infectious glomerulonephritis.

• Chronic kidney disease: CKD develops over months to years with progressive renal insufficiency, azotemia, and electrolyte imbalances. The child has normal kidney function aside from proteinuria and edema, indicating acute onset rather than chronic progression.

• Hemolytic uremic syndrome: HUS often presents with microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury following diarrhea. Although the child has proteinuria and edema, hemoglobin and platelet counts do not indicate HUS. Lab pattern and history do not support this diagnosis.

• Administer IV antibiotics: There is no evidence of bacterial infection; labs and clinical presentation point to proteinuria from nephrotic syndrome rather than infection. Antibiotics would not address the underlying glomerular pathology.

• Initiate peritoneal dialysis: Renal function is not severely impaired; serum creatinine is not reported elevated. Dialysis is unnecessary in uncomplicated nephrotic syndrome. Conservative management with diet and corticosteroids is appropriate.

• Initiate contact precautions: No infectious etiology is present. Contact precautions are not indicated. The condition is glomerular in origin, not transmissible.

• Abnormal HbA1c: Blood glucose or HbA1c is not relevant; the child does not have diabetes. This parameter does not assess nephrotic syndrome progression.

• Bilirubin: There is no evidence of hemolysis or liver dysfunction; bilirubin is not a relevant parameter. Monitoring bilirubin does not reflect nephrotic syndrome severity.

• Head circumference: Head circumference is not relevant in school-age children for assessing edema or renal disease. Changes in girth relate more to abdominal fluid retention than cranial growth at this age.

A. Report the incident to the nurse manager: Reporting to the nurse manager is important for institutional accountability and guidance, but it is not the immediate priority. The client’s safety must be addressed first.

B. Measure the client's vital signs: Assessing the client’s current condition, including vital signs, is the first action because it identifies any immediate physiologic effects of the medication error. This assessment guides subsequent interventions and determines the urgency of notifying the provider.

C. Fill out an incident report: Completing an incident report is required for documentation and quality improvement, but it is secondary to ensuring the client’s safety and assessing for adverse effects.

D. Notify the provider: The provider must be informed to determine medical interventions, but this step follows the initial assessment of the client to establish their current status and identify any immediate threats to safety.