A nurse is caring for a client who is 36 weeks of gestation and experiences a spontaneous rupture of membranes. Which of the following actions should the nurse take?

Rationale for Correct Choices:

• Decrease environmental stimulation: Reducing stimulation helps manage restlessness by preventing sensory overload, which can exacerbate agitation in clients with schizophrenia. A calm environment supports focus and reduces the risk of escalation or aggressive behavior.
• Provide constructive diversions: Constructive diversions such as quiet activities or art can channel aggressive energy into safe outlets. For a client expressing paranoia and aggression toward staff, structured and non-threatening engagement is therapeutic and promotes emotional regulation.
• Use visual cues to promote attention to tasks: Clients with schizophrenia often struggle with distractibility and disorganized thought processes. Visual prompts and step-by-step guides help them focus and complete hygiene tasks that would otherwise be overwhelming or forgotten.

Rationale for Incorrect Choices:

• Avoid discussing the client’s negative emotions: Suppressing emotional expression is countertherapeutic. Clients benefit from validating their emotions through supportive communication, which also builds trust and rapport necessary for effective care.
• Discourage participation in physical exercise: Exercise can be beneficial in reducing anxiety and agitation. Discouraging movement may increase restlessness or internal distress in clients who need outlets for excess energy.
• Minimize engagement with the client: Withdrawal from the client may reinforce feelings of paranoia or abandonment. Consistent therapeutic engagement is essential for building trust and managing disruptive behaviors.
• Place the client in a room away from the nurses’ station: Isolating a paranoid and aggressive client may increase their risk of harming themselves or others. Close observation near the nurses’ station ensures safety and quick intervention if escalation occurs.
• Instruct client to perform tasks independently: Clients with cognitive disruptions may not be able to initiate or complete hygiene without cues. Expecting full independence without support can lead to frustration, noncompliance, or neglect of self-care.
• Enact consequences for uncompleted hygiene tasks: Punitive measures are inappropriate for clients with psychiatric disorders who are impaired in their ability to carry out daily routines. Behavioral reinforcement must be therapeutic and supportive, not disciplinary.

Rationale:

A. Temperature 36.8° C (98° F): This temperature is within the normal range and does not suggest a current or impending infection. It indicates stable thermoregulation in the postoperative period.

B. White blood cell count 8,000/mm³ (5,000 to 10,000/mm³): This WBC count falls within the normal reference range and does not reflect infection or inflammation. No abnormal immune response is indicated by this result.

C. Body mass index of 32: A BMI over 30 is classified as obesity, which increases the risk of poor wound healing and surgical site infections. Excess adipose tissue can impair circulation, oxygenation, and immune response at the wound site.

D. Blood glucose 90 mg/dL (74 to 106 mg/dL): This is a normal fasting glucose level and does not contribute to infection risk. Well-controlled glucose levels are favorable for wound healing and immune function.