A nurse is collecting data from a client who has heart failure and edema of the lower extremities. Which of the following actions should the nurse take to monitor for pitting edema?

An ascending colostomy is a surgical opening created in the ascending colon to divert fecal flow to an external pouch. Because it is located in the proximal large intestine, stool output is typically liquid to semi-liquid with high enzyme content. Postoperative teaching focuses on stoma care, expected stool characteristics, and recognition of complications such as ischemia. Monitoring stoma color is critical because it reflects blood supply and tissue viability.

Rationale:
A. Avoiding nuts is not a universal requirement for clients with a colostomy. While some foods may initially cause gas or blockage concerns, dietary restrictions are individualized rather than completely eliminating specific food groups. Clients are usually encouraged to gradually reintroduce foods while monitoring tolerance.

B. Irrigating the colostomy every day is not appropriate for an ascending colostomy. Irrigation is typically used for descending or sigmoid colostomies to regulate bowel emptying. An ascending colostomy produces frequent liquid output, making irrigation unnecessary and ineffective.

C. Expecting formed stool is incorrect for an ascending colostomy because stool at this level of the colon is still liquid to semi-liquid due to limited water reabsorption. Formed stool is more typical of descending or sigmoid colostomies where more water has been absorbed.

D. A stoma that appears purple is an abnormal finding indicating compromised blood flow or possible ischemia. A healthy stoma should be pink to red and moist. Any color change such as purple, dusky, or black should be reported immediately because it may indicate necrosis requiring urgent intervention.

The client presents with severe hypertension, proteinuria, hyperreflexia, edema, and elevated liver enzymes, all consistent with worsening preeclampsia with risk for end-organ involvement. Severe preeclampsia can rapidly progress to eclampsia (seizures) and placental abruption due to poor placental perfusion and vascular instability. Early recognition of these complications is critical for maternal and fetal safety.

Rationale for correct choices:

• Seizures are the defining feature of eclampsia, which is a severe complication of preeclampsia. The client already demonstrates severe hypertension, hyperreflexia (4+ reflexes), and proteinuria, indicating significant central nervous system irritability. These findings increase the risk of cerebral edema and seizure activity. Without prompt management, preeclampsia can progress to eclampsia, which is life-threatening for both mother and fetus.

• Placental abruption is a serious complication of preeclampsia caused by vasospasm and impaired placental perfusion leading to premature separation of the placenta from the uterine wall. Severe hypertension and endothelial damage increase this risk. Although fetal status is currently stable, the underlying vascular instability places the client at high risk. Abruptions can lead to fetal distress, hemorrhage, and maternal instability.

Rationale for incorrect choices:

• Cervical insufficiency is a structural problem of the cervix that leads to painless cervical dilation and preterm birth, typically unrelated to hypertensive disorders of pregnancy. This client’s condition is driven by vascular and systemic endothelial dysfunction rather than cervical weakness. There ae no cervical changes or painless dilation in the assessment. Therefore, it is not a likely complication.

• Although preeclampsia can cause fluid shifts and increased vascular resistance, this client does not show clinical signs of cardiac failure such as pulmonary edema, crackles, or decreased oxygenation. Oxygen saturation is normal, and lung sounds are normal. Although edema is present, it is more consistent with preeclampsia-related fluid retention.

• Hypoglycemia is not associated with preeclampsia or hypertensive disorders of pregnancy. The client’s blood glucose is within normal limits, and there is no evidence of insulin use or fasting state contributing to low blood sugar. The symptoms and laboratory findings are unrelated to glucose metabolism. Therefore, hypoglycemia is not a relevant complication.