A nurse is caring for a client who is pregnant. The nurse is reviewing the client's medical record.

Exhibits

Select 4 findings that indicate a potential prenatal complication

Rationale:

A. Keep objects in the client's room in the same place: Maintaining a consistent environment helps clients with vision loss navigate safely and confidently. Sudden changes in object placement can increase the risk of disorientation and injury.

B. Ensure there is high-wattage lighting in the client's room: While good lighting benefits clients with partial vision, high-wattage lighting can cause glare or discomfort. The focus should be on well-distributed, non-glare lighting suited to individual needs rather than universally high intensity.

C. Touch the client gently to announce presence: Gently touching a visually impaired client before speaking helps avoid startling them and fosters trust. It is a respectful way to make presence known when visual cues are unavailable.

D. Approach the client from the side: Approaching from the front is preferable so the client can better perceive the nurse's presence through remaining visual fields or auditory cues. Side approaches may lead to disorientation or surprise.

E. Allow extra time for the client to perform tasks: Clients with vision loss may require additional time to complete self-care or communication tasks. Rushing them can increase stress and compromise safety, so patience supports their independence.

Rationale:

A. "Let's talk about what you already know about immunizing your baby.": This response uses open-ended, nonjudgmental communication to explore the parents' beliefs and knowledge. It encourages dialogue, builds trust, and opens the door for education about vaccine safety and benefits.

B. "Your baby's immunizations should be up to date before they are able to travel with you by airplane.": This statement may feel coercive or irrelevant if the parents are not currently planning to travel. It does not address their current concerns or promote open discussion.

C. "You don't have to immunize your baby against diseases that are no longer common.": Diseases like measles and pertussis can still occur and spread quickly in under-immunized communities. Vaccination remains essential to maintain herd immunity and prevent outbreaks.

D. "The provider can give you a referral for your baby to see an infectious disease provider.": Referring to a specialist at this stage may come across as dismissive or escalate the situation unnecessarily. Primary care providers and nurses can often address vaccine concerns effectively through discussion and education.