A nurse is caring for a client who has a new prescription for total parenteral nutrition with fat emulsion. Which of the following findings should the nurse report to the provider?

Rationale for Correct Choices:

• Blurred vision: Amitriptyline causes anticholinergic effects such as blurred vision by impairing lens accommodation. This effect is common in the early stages of treatment and may improve over time.
• Orthostatic hypotension: Amitriptyline reduces peripheral vascular resistance, which can cause blood pressure to drop when a client changes position. This increases the risk for falls, especially in older adults.
• Urinary retention: Anticholinergic effects from amitriptyline reduce bladder contractility, leading to urinary retention. This is especially concerning in clients with prostate enlargement or existing urinary difficulties.
• Constipation: Decreased gastrointestinal motility caused by anticholinergic activity makes constipation a common and expected side effect. Clients should be advised to increase fiber and fluid intake.

Rationale for Incorrect Choices:

• HEENT: Hearing loss is not associated with tricyclic antidepressants like amitriptyline, which do not affect the auditory system. Photophobia typically results from conditions like migraines or uveitis, not from tricyclic antidepressant use.
• Cardiovascular: Hypertension is not a known side effect of amitriptyline. The medication more commonly lowers blood pressure through vasodilation. Bradycardia is not expected with amitriptyline. In fact, the drug may cause tachycardia due to its effect on cardiac conduction.
• Genitourinary: Urinary incontinence is not typical with amitriptyline. The drug’s anticholinergic properties reduce bladder contractility, increasing the risk of retention instead. Increased libido is not a side effect of tricyclic antidepressants. These medications are more likely to decrease libido and may contribute to sexual dysfunction.
• Gastrointestinal: Dry mouth is a common anticholinergic effect but does not directly impact gastrointestinal motility, making it a less appropriate answer in this system category. Diarrhea is not expected with anticholinergic drugs like amitriptyline, which slow bowel movements and increase the risk for constipation.

Rationale:

A. Initiate fundal massage: Fundal massage is performed after delivery to prevent or manage uterine atony and postpartum hemorrhage. It is not appropriate during active labor, especially before the birth of the fetus.

B. Apply a fetal heart rate monitor: After rupture of membranes, there is an increased risk of umbilical cord prolapse or fetal distress. Continuous fetal monitoring is essential to assess fetal well-being and detect complications promptly.

C. Insert an indwelling urinary catheter: While catheterization may be done later, especially before epidural placement or cesarean delivery, it is not the most urgent action. It does not address immediate risks associated with ruptured membranes.

D. Initiate an oxytocin IV infusion: Oxytocin is used to augment or induce labor, but should not be started without first assessing fetal status. Fetal monitoring is necessary to establish a baseline before initiating uterotonic agents.