A nurse is caring for an adolescent client who is pregnant with their second child and is experiencing anxiety. Which of the following statements should the nurse make?

Rationale:

A. Acetaminophen: Acetaminophen is generally considered safe during pregnancy when used at recommended doses. It is commonly used to treat mild pain and fever without significant risk to the fetus.

B. Saline nasal spray: Saline nasal sprays are non-medicated and safe for use during pregnancy. They help relieve nasal congestion without systemic absorption or risk to fetal development.

C. Levothyroxine: Levothyroxine is a thyroid hormone replacement that is safe and essential during pregnancy for clients with hypothyroidism. Untreated hypothyroidism poses greater risks to both mother and fetus than the medication itself.

D. Ibuprofen: Ibuprofen is contraindicated, especially during the third trimester, due to risks such as premature closure of the ductus arteriosus, oligohydramnios, and delayed labor. Acetaminophen is preferred for pain relief in pregnancy.

Rationale:

A. A client who has heart failure and received a diuretic 30 min ago: While this client should be monitored for urine output and signs of dehydration or electrolyte imbalance, there is no indication of acute distress requiring immediate attention.

B. A client who has hypertension and reports a severe headache: This could indicate a hypertensive crisis or impending stroke, both of which are life-threatening and require urgent assessment and intervention to prevent neurological damage or organ failure.

C. A client who reports frequent and painful urination: These are signs of a urinary tract infection, which, while uncomfortable, is not typically emergent unless accompanied by fever, flank pain, or systemic symptoms.

D. A client who reports left arm pain following a fall: The arm pain may indicate a fracture, but it is less urgent than potential end-organ damage from a hypertensive emergency, assuming no deformity or vascular compromise is described.