A nurse is obtaining a blood specimen from a client who has a peripherally inserted central catheter. Which of the following actions should the nurse take?

A. Slurred speech: Slurred speech is typically associated with intoxication from central nervous system depressants, such as alcohol or opioids, rather than withdrawal. During withdrawal, the client is more likely to exhibit hyperactive or restless behavior.

B. Constricted pupils: Pupillary constriction (miosis) occurs with opioid intoxication. In contrast, opioid withdrawal usually causes dilated pupils (mydriasis) due to sympathetic nervous system overactivity.

C. Sedation: Sedation is a common effect of opioid use, not withdrawal. During withdrawal, clients are generally hyperalert, restless, and may experience insomnia rather than excessive sleepiness.

D. Yawning: Yawning is a classic sign of opioid withdrawal and reflects autonomic nervous system activation. It is often accompanied by lacrimation, rhinorrhea, sweating, and other early withdrawal symptoms.

Rationale for correct choices

• Evaluating the fetal heart rate tracing: The client is at 31 weeks of gestation with decreased fetal movement, a sign of potential fetal compromise. Assessing the fetal heart rate immediately allows the nurse to determine fetal well-being and identify any signs of distress. Prompt evaluation is critical in high-risk pregnancies, especially with maternal hypertension and preeclampsia, to guide timely interventions.

• Administering antihypertensives: The client’s blood pressure readings (162/112 mm Hg and 166/110 mm Hg) indicate severe hypertension, increasing the risk for maternal complications such as stroke and eclampsia. Administering prescribed antihypertensives after assessing fetal status helps stabilize maternal blood pressure while maintaining fetal perfusion.

Rationale for incorrect choices

• Administering acetaminophen PO: While the client reports a severe headache, acetaminophen only addresses pain symptomatically and does not treat the underlying severe hypertension or fetal risk. Managing maternal blood pressure and assessing fetal status take priority over analgesic administration in this scenario.

• Obtaining 24-hour urine collection: A 24-hour urine collection to measure proteinuria is important for diagnosing preeclampsia severity, but it is not an immediate action. It is time-consuming and does not provide real-time data on maternal or fetal well-being, so it should follow urgent interventions.

• Administering antibiotics: There is no evidence of infection in the client’s assessment or laboratory findings, so antibiotics are not indicated at this time. Initiating antibiotics would not address the acute maternal or fetal risks associated with severe preeclampsia.

• Encouraging ambulation: Encouraging ambulation is inappropriate in a client with severe hypertension and decreased fetal movement because physical activity could exacerbate maternal risk and stress the fetus. Bed rest and monitoring are safer until the client is stabilized.