A nurse is caring for a client who has hearing loss. While communicating with the client, which of the following actions should the nurse take?

Rationale:

A. Initiate contact precautions: No signs of infection or communicable disease are present, so contact precautions are unnecessary.

B. Decrease lighting in the client’s room: The client is restless and later becomes lethargic, suggesting neurological irritability or worsening preeclampsia. Reducing environmental stimuli like lighting can help minimize seizures and agitation.

C. Check urinary output: The client’s urine output decreased to 20 mL in one hour, which is concerning for renal impairment often seen in severe preeclampsia. Monitoring output closely helps detect worsening kidney function and fluid balance.

D. Prepare for amniocentesis: There is no indication for amniocentesis in this clinical scenario related to preeclampsia or maternal condition.

E. Encourage bed rest: Bed rest in the side-lying position improves uteroplacental perfusion and helps control blood pressure, reducing the risk of complications from preeclampsia.

F. Monitor blood pressure: Blood pressure is elevated and critical to assess frequently to evaluate disease progression and prevent hypertensive emergencies or seizures.

G. Apply internal fetal monitor: The client has no contractions and a stable external fetal heart rate. Internal monitoring is invasive and reserved for active labor or when external monitoring is insufficient.

H. Assess DTR: The shift from hyperreflexia (3+) to hyporeflexia (1+) may indicate worsening neurological status or magnesium sulfate toxicity if administered. Continuous monitoring is essential.

Rationale:

A. Institutional policies and procedures: While helpful in guiding facility-specific protocols, policies do not override state regulations. An institution may allow tasks that exceed or fall short of legal scope, so this should not be the primary reference.

B. Written prescription from the provider: A provider’s order does not define or expand a nurse’s legal scope of practice. Even with a valid order, the nurse must independently verify whether they are legally permitted to carry out the task.

C. State Nurse Practice Act: The Nurse Practice Act (NPA) is the legal authority that defines what licensed nurses are permitted to do in their state. It is the most authoritative resource to determine whether a task is within the nurse’s legal scope of practice.

D. Verbal direction from the nurse manager: Even when given by a superior, verbal instructions must still comply with state law. A nurse manager’s guidance cannot authorize a task that lies outside the nurse’s legal scope.