A nurse is planning care for a client who is at 36 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse plan to implement?

Rationale for correct choices

• Inspect the child's oropharynx: Vomiting bright red emesis after tonsillectomy indicates possible postoperative hemorrhage. Immediate inspection of the oropharynx allows the nurse to assess the source, amount, and severity of bleeding. Prompt identification of bleeding is critical to prevent hypovolemic shock and guide urgent interventions.

• Obtaining a set of vital signs: Vital signs provide objective data about the child’s hemodynamic status. Tachycardia, hypotension, or altered respiratory rate may indicate significant blood loss. Monitoring blood pressure, heart rate, and oxygen saturation helps determine the urgency of treatment and guides fluid resuscitation or other emergency measures.

Rationale for incorrect choices

• Place the child in a supine position: Placing the child supine could worsen bleeding or increase the risk of aspiration if emesis occurs. Standard care is to maintain the child upright or sitting forward to allow drainage and minimize airway compromise. Supine positioning is not appropriate immediately after post-tonsillectomy bleeding.

• Offer the child a red popsicle: Red-colored foods or drinks can mask the presence of ongoing bleeding, delaying recognition of hemorrhage. It is unsafe to offer red popsicles until bleeding is ruled out and the child is stable. Non-red liquids or clear fluids are safer during assessment.

• Encouraging the child to cough and deep breathe: While coughing and deep breathing are important for postoperative respiratory care, they are contraindicated if active bleeding is suspected. Coughing could dislodge clots and exacerbate hemorrhage. Airway safety and hemodynamic assessment take priority.

• Requesting a prescription for codeine: Administering codeine for pain is inappropriate in the presence of suspected bleeding because opioids can mask symptoms and depress respirations. Pain management should be secondary to stabilization and assessment of hemorrhage risk.

Rationale:

A. Decreased inflammation: Furosemide is a loop diuretic that reduces fluid volume by promoting diuresis. While reducing edema may decrease swelling, “decreased inflammation” is not the primary measure of effectiveness for furosemide, as inflammation involves cellular processes rather than fluid removal.

B. Increased blood pressure: Furosemide typically lowers blood pressure by reducing circulating fluid volume. An increase in blood pressure would suggest the medication is not effective or another underlying issue is present, so this is not an expected finding.

C. Decreased pain: Pain reduction may occur indirectly if edema is relieved, but it is not a direct indicator of furosemide’s effectiveness. Pain levels are subjective and can be influenced by multiple factors, making this a less reliable measure.

D. Weight loss: A reduction in body weight reflects fluid loss, which is the primary therapeutic effect of furosemide. Monitoring daily weights is a standard and objective way to evaluate the effectiveness of diuretic therapy in clients with fluid volume excess.