A nurse is caring for a client who is at 33 weeks of gestation, has eclampsia, and is experiencing a seizure.
Which of the following actions should the nurse take following the seizure.

Choice A rationale

Veracity is the ethical principle of telling the truth and being honest with clients. By informing the client about the potential side effect of lightheadedness while also clarifying that the procedure should not affect their memory, the nurse is providing accurate and complete information. This honesty allows the client to make an informed decision and builds trust in the therapeutic relationship. The nurse is being truthful about the known risks and benefits of the treatment.

Choice B rationale

Beneficence is the ethical principle of doing good and acting in the best interest of the client. While the nurse's actions are ultimately intended to be beneficial, the specific act of providing truthful information is a demonstration of veracity. Beneficence would involve ensuring the treatment is appropriate and safe for the client, whereas veracity is the specific communication of the truth about that treatment's effects.

Choice C rationale

Autonomy is the ethical principle that respects a client's right to self-determination and to make their own decisions. While providing truthful information supports the client's ability to exercise their autonomy, the act of giving the information itself is an example of veracity. The nurse is upholding the client's autonomy by being truthful, but the action of being truthful is the core principle demonstrated.

Choice D rationale

Fidelity is the ethical principle of keeping promises and being loyal to the client. This involves maintaining professional commitments and a trusting relationship. While providing accurate information contributes to a trusting relationship, it is a direct fulfillment of the duty of veracity. Fidelity is more about honoring commitments and promises, which is a broader concept than simply telling the truth about a procedure's effects. *.

Choice A rationale: A protective environment is typically indicated for immunocompromised clients, such as those with neutropenia or undergoing chemotherapy, not for uncomplicated anemia. The toddler’s white blood cell count is within the normal range of 5,000 to 10,000/mm³, and no evidence of infection risk or severe immunodeficiency is present. Pallor and low hemoglobin are consistent with iron deficiency anemia, which does not require isolation precautions unless additional hematologic compromise is identified.

Choice B rationale: Blood transfusions are reserved for cases of severe anemia with hemodynamic instability, cardiac compromise, or hemoglobin levels below 7 g/dL. This toddler’s hemoglobin is 8.1 g/dL, which while low, does not meet transfusion threshold in a stable, asymptomatic pediatric patient. Transfusion carries risks like iron overload and alloimmunization, making it inappropriate for mild to moderate anemia. Instead, correction through dietary modification and iron supplementation is preferred for age-related iron-deficiency anemia.

Choice C rationale: Iron supplementation is the standard therapy for iron deficiency anemia, especially in toddlers consuming excessive cow’s milk, which lacks iron and can cause occult intestinal blood loss. Hemoglobin of 8.1 g/dL is below the normal pediatric range of 9.5 to 14 g/dL, confirming anemia. Iron replenishment stimulates erythropoiesis by enabling hemoglobin synthesis. Supplementation corrects deficiency over time and should be paired with dietary education to limit milk to <24 oz/day and include iron-rich foods.

Choice D rationale: Continuing antibiotics is unnecessary unless there is ongoing infection. The toddler has recently completed antibiotic therapy for otitis media, and current symptoms do not suggest infection recurrence. Vital signs are stable and the white blood cell count is within normal limits (5,000–10,000/mm³), indicating no acute bacterial process. Antibiotic overuse may disrupt gut flora, impair iron absorption, and contribute to resistant bacterial strains, which is contraindicated in this clinical scenario.