A nurse is caring for a client who is at 36 weeks of gestation and is undergoing a nonstress test (NST). The test is nonreactive. Which of the following interventions should the nurse suggest based on the findings?

A. Encourage oral fluid intake. The client has pink urine, which may indicate mild hematuria. While the urine output is adequate, increasing fluid intake can help dilute the urine, reduce irritation, and promote overall hydration. Additionally, increased fluid intake can aid in softening stool and preventing further constipation.
B. Administer an enema. The client reports abdominal cramping and a small, hard, painful bowel movement, indicating constipation. Postoperative clients are at risk for constipation due to decreased mobility, opioid pain medications, and anesthesia effects. Administering an enema can help relieve discomfort and promote bowel movements.
C. Irrigate indwelling catheter with 500 mL of fluid. The client's urinary catheter is intact, and there is a consistent urine output of 100 mL/hr. The presence of pink urine does not indicate obstruction requiring catheter irrigation. Irrigation with such a large volume could introduce unnecessary risk and is not warranted at this time.
D. Assist the client with a sitz bath. Sitz baths are typically used for perineal discomfort, such as after perineal surgery, hemorrhoids, or childbirth. There is no indication in the nurse’s notes that the client has perineal pain or a condition requiring a sitz bath.
E. Encourage prolonged dangling before ambulation. The client is already ambulating independently, indicating no significant issues with orthostatic hypotension or weakness. Encouraging prolonged dangling is unnecessary and could delay mobility, which is essential for preventing complications such as constipation and venous thromboembolism.

A. "You might experience swollen gums while taking this medication." Phenytoin is known to cause gingival hyperplasia, which is swelling and overgrowth of the gums. This is a common side effect, and clients should be informed about it so they can maintain good oral hygiene and seek dental care if necessary.
B. "You can skip a dose of this medication if you are nauseated." Skipping doses is not advised. Phenytoin should be taken consistently, and skipping doses can lead to decreased seizure control. If nausea occurs, the client should contact their healthcare provider for guidance.
C. "You can safely take this medication if you become pregnant." Phenytoin is classified as a Category D medication, indicating evidence of risk to the fetus. Women of childbearing age should discuss effective contraception and consult their healthcare provider regarding the risks associated with taking phenytoin during pregnancy.
D. "You should expect to have blood work every 6 months while taking this medication." Regular monitoring of serum levels is necessary, typically every 1-3 months, especially after dosage changes. Monitoring ensures therapeutic levels and prevents toxicity, so stating that blood work is only required every 6 months may be insufficient.