A nurse is caring for a client who is pregnant.

Exhibits

The nurse is reviewing the client's medical record.
Select 4 findings that indicate a potential prenatal complication.

Rationale:
A. The nurse positions a client who is postoperative in a semi-Fowler's position: Semi-Fowler’s promotes lung expansion and comfort postoperatively, especially after abdominal or thoracic surgery, making this an appropriate nursing action.

B. The nurse uses clean gloves when administering an enema: Clean gloves are sufficient for enema administration since it is a clean (not sterile) procedure, and this reflects correct practice.

C. The nurse performs auscultation of the lungs without lifting the gown: Clothing or gowns interfere with accurate transmission of breath sounds, leading to possible misinterpretation. The gown should be lifted or moved aside to properly auscultate.

D. The nurse applies a cold compress to reduce localized swelling: Cold therapy decreases blood flow and inflammation, making this an appropriate intervention for localized swelling or injury.

Rationale:
A. "Did you tell your provider that your family doesn't agree with your decision?": While it’s appropriate for the provider to be aware of family concerns, this response diverts focus away from the client’s feelings and does not promote open communication. The nurse should first explore the client’s emotions and perspective before suggesting further discussion.

B. "You are making the same decision I would make.": This statement introduces the nurse’s personal opinion, which is nontherapeutic and shifts focus away from the client. It does not encourage expression of the client’s own values, beliefs, or reasoning behind her decision.

C. "You should get your family to agree with your decision before signing the consent.": The client’s consent is based on her own autonomy, not family approval. Suggesting she must gain their agreement undermines her right to make independent healthcare decisions.

D. "Your family disagrees with your decision?": This therapeutic, open-ended response encourages the client to share more about her family’s feelings and her own emotional experience. It demonstrates active listening, fosters trust, and allows the nurse to better understand and support the client’s perspective.