A nurse is caring for a client who is pregnant.

Exhibits

The nurse is reviewing the client's assessment findings.

For each of the client's assessment finding. click to specify if the finding is consistent with preeclampsia with severe features or HELLP syndrome. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

A. Blood verification is always done by two licensed nurses to ensure compatibility between the donor unit and the recipient. This prevents fatal transfusion reactions due to ABO or Rh incompatibility.

B. Older adults are at higher risk for fluid overload and transfusion-associated circulatory overload (TACO). Assessing baseline lung sounds helps identify early signs of pulmonary edema or heart failure during the transfusion.

C. Sterile gloves are not required for blood administration setup. The nurse should use clean gloves because the blood and tubing are sterile from the manufacturer; sterile gloves are only used for sterile procedures.

D. Each unit of packed RBCs should be infused within 2 to 4 hours to prevent bacterial proliferation in the blood. For older adults, infusing more slowly (up to 4 hours) helps prevent fluid overload while still maintaining safety.

E. Blood must be primed with 0.9% sodium chloride (normal saline) — not hypotonic saline (0.45%) — because other solutions can cause hemolysis or clotting of red blood cells.

Parent Statements Reflecting Understanding:

“We should prop the casted arm on pillows for the next 24 hours.” This demonstrates understanding because elevating the casted arm helps reduce swelling, improve circulation, and increase comfort during the initial period after casting. Proper elevation is an essential part of post-cast care.

“It is important that our child avoids placing anything inside the cast.” This shows correct understanding because inserting objects inside the cast can damage the skin, cause irritation, or lead to infection. Avoiding insertion of objects helps protect the skin and maintain safe healing conditions.

“We need to be very careful about how we handle the cast for the first 2 days while it dries.” This reflects understanding because a cast is still soft and vulnerable immediately after application. Gentle handling ensures the cast maintains proper alignment, which is critical for proper bone healing.

“We should notify the provider if the cast becomes loose over time.” This demonstrates understanding because a loose cast can compromise immobilization, potentially leading to improper healing or displacement of the fracture. Notifying the provider ensures timely correction.

Parent Statements Needing Reinforcement:

“We should expect the swelling and tingling to worsen before it gets better.” This statement indicates a misunderstanding. In a properly casted limb, swelling and tingling should gradually improve, not worsen. Worsening symptoms may suggest neurovascular compromise, which is an urgent condition requiring immediate evaluation by a healthcare provider. Parents need reinforcement that persistent or increasing tingling, numbness, pain, or changes in color of the fingers are warning signs and should not be ignored.