A nurse is caring for a client who has an abruptio placentae. Which of the following findings should the nurse expect?

Rationale:

A. Arrange for an ethics committee meeting to address the family's concerns: An ethics committee helps resolve conflicts between families and healthcare teams while respecting patient autonomy and legal directives. This step promotes ethical decision-making and interdisciplinary collaboration.

B. Support the family's decision and initiate life-sustaining measures: Providing treatments against the client’s documented wishes violates ethical and legal standards. Advance directives must be honored, even when family members disagree.

C. Complete an incident report: An incident report is used to document errors or adverse events, not ethical conflicts. This situation requires ethical consultation and communication, not a formal incident report.

D. Encourage the family to contact an attorney: While families may seek legal counsel, it is not the nurse’s role to suggest legal action. This may escalate the conflict unnecessarily and delay proper ethical resolution.

Rationale for correct choices:

• Blood pressure: A reading of 148/94 mm Hg is elevated and meets criteria for gestational hypertension, especially in a client who is gravida 1 para 0. It raises concern for preeclampsia and must be closely monitored, particularly with concurrent symptoms like headache and edema.
• DTR: A deep tendon reflex of 3+ is considered hyperreflexic and may signal increased central nervous system irritability. In the setting of elevated blood pressure and other preeclampsia signs, it raises concern for worsening severity or impending seizure activity.
• Lower extremity assessment: The presence of 1+ dependent edema can be a normal pregnancy finding, but when paired with facial swelling, recent weight gain, and elevated blood pressure, it becomes significant and suggests fluid retention associated with preeclampsia.
• Weight assessment: A gain of 0.68 kg (1.5 lb) in a week may seem modest, but when it is sudden and combined with facial and dependent edema, it can indicate abnormal fluid accumulation. This pattern is concerning for preeclampsia and requires follow-up.
• Nausea: While nausea is common in pregnancy, its presence along with right upper quadrant pain and headache raises red flags for severe preeclampsia or HELLP syndrome. These are warning signs of potential hepatic involvement or worsening disease.

Rationale for incorrect choices:

• Fundal height: A fundal height of 29 cm is consistent with gestational age around 29 weeks and does not indicate an abnormal finding in this context. No follow-up is needed unless measurements are inconsistent with gestational dating.
• Respiratory assessment: The client’s lungs are clear to auscultation and respirations are even and non-labored. Oxygen saturation is 95% on room air, which is within normal range during pregnancy, so no respiratory issues require intervention.
• Fetal heart tracing: A fetal heart rate of 140/min is within the normal range of 110–160 beats per minute. There are no reported decelerations or signs of distress, so no immediate follow-up is indicated for the fetal tracing.