A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. The client reports that she is experiencing difficulty breathing. Which of the following actions should the nurse take first?

Rationale:

A. Clamp the catheter distal to the injection port: Clamping the catheter allows urine to accumulate in the tubing, ensuring a fresh specimen can be obtained from the sampling port rather than from stagnant urine in the drainage bag, which could be contaminated.

B. Drain the specimen from the drainage bag: Urine in the drainage bag may be old and contaminated, which can lead to inaccurate culture results. Specimens should be collected aseptically from the catheter sampling port.

C. Collect 2 mL of urine for each specimen: For accurate urinalysis and culture, a larger volume typically 3–10 mL for culture and 10–15 mL for routine urinalysis is recommended to ensure enough specimen for testing and repeat analysis if needed.

D. Obtain the urinalysis specimen before the culture specimen: Culture specimens should be collected first to prevent contamination. Performing urinalysis first can alter the bacterial composition of the sample and compromise culture accuracy.

Rationale:

A. Use a mummy restraint to hold the child during the catheter insertion: Physical restraints should be used only as a last resort, as they can increase anxiety and trauma. Non-pharmacologic methods and parental support are preferred for safely holding a child during procedures.

B. Perform the procedure in the child's room: Conducting the IV insertion in the child’s room helps reduce stress by providing a familiar environment. It also allows parental presence, which can comfort the child and improve cooperation.

C. Require the parents to leave the room during the procedure: Removing parents can increase the child’s anxiety and reduce emotional support. Parental presence is generally encouraged to help the child feel safe during invasive procedures.

D. Tell the child there will be discomfort during the catheter insertion: The nurse should provide age-appropriate explanations using simple, honest language, focusing on sensations rather than labeling it as painful, to reduce fear and encourage cooperation.