A nurse is planning care for a client who is at 16 weeks of gestation and has hyperemesis gravidarum. Which of the following actions should the nurse anticipate taking?

• Assist with titrating the rate of infusion to maintain the client's blood pressure at 90/60 mm Hg or above: The client has hypotension due to gastrointestinal bleeding, and blood transfusion can help restore intravascular volume. Adjusting the transfusion rate to maintain adequate perfusion is necessary.
• Document the blood product transfusion in the client's medical record: It is necessary to document the administration of blood products, including vital signs, volume infused, and any reactions, to ensure accurate medical records.
• Assist with obtaining the first unit of packed RBCs from the blood bank: Blood products must be obtained from the blood bank following facility protocol, ensuring proper identification and verification before administration.
• Monitor the client for the first 15 min of the transfusion: The client is at risk for transfusion reactions, which are most likely to occur within the first 15 minutes. Close monitoring allows for early detection and intervention.

Not Indicated:

• Start an IV bolus of lactated Ringer's solution: The provider prescribed 0.9% sodium chloride, not lactated Ringer’s solution. Using the correct fluid is important to avoid potential electrolyte imbalances.
• Discard the blood bag in the client's trash can after the transfusion: Blood product bags must be disposed of in a biohazard container to comply with infection control policies and prevent contamination.

A. "Can you tell me about the stresses in your life?" Identifying stressors is important for understanding the client’s situation, but it does not directly assess the immediate risk of suicide, which takes priority.
B. "Has anyone in your family ever died by suicide?" A family history of suicide can be a risk factor, but assessing the client’s current intent and plan is more urgent for determining immediate safety.
C. "Do you have someone to discuss your feelings with?" A support system is important, but it does not address the immediate risk of self-harm. If the client has a plan, immediate intervention is needed regardless of their support system.
D. "Do you have a plan for harming yourself?" Asking about a specific plan is the priority because it helps determine the level of risk and urgency of intervention. A detailed plan suggests a higher risk of acting on suicidal thoughts, requiring immediate safety measures.