A nurse is planning care prior to an amniocentesis for a client who is at 22 weeks of gestation. Which of the following actions should the nurse include in the plan of care?

Rationale:

A. Sleep pattern: Two days without sleep is a red flag in bipolar disorder and may lead to worsening mania or psychosis. Addressing sleep deprivation is a priority to reduce the risk of exhaustion or psychotic deterioration.

B. Skin turgor: Poor skin turgor suggests dehydration, which may be due to poor fluid intake or prolonged activity. It requires immediate follow-up to prevent complications like electrolyte imbalances or renal injury.

C. Hallucinations: Persistent visual hallucinations may indicate an acute psychotic episode or manic psychosis. These require immediate psychiatric intervention to ensure client safety and stabilization.

D. Heart rate: A heart rate of 120/min indicates tachycardia, possibly related to dehydration, agitation, or underlying mania. It requires prompt evaluation to rule out cardiovascular strain or systemic causes.

E. Hygiene: While poor hygiene is a concern and can indicate mental health deterioration, it is not immediately life-threatening. It can be addressed after acute issues such as dehydration, tachycardia, and psychosis are managed.

Rationale:

A. Apply direct pressure to the wound with thick dressing material: Direct pressure is the first-line intervention for controlling active external bleeding. Applying firm pressure with thick, sterile dressing helps tamponade the bleeding vessel and minimizes blood loss while awaiting further treatment.

B. Apply a transparent dressing to the wound: Transparent dressings are used for minor wounds or IV sites, not for managing active bleeding. They do not provide the necessary compression to control hemorrhage from a deep or penetrating injury.

C. Irrigate the wound with sterile water: Wound irrigation is appropriate for cleaning minor wounds or after bleeding is controlled. Irrigating during active bleeding can delay hemostasis and increase blood loss.

D. Tie a tourniquet around the leg distal to the wound: A tourniquet, if necessary, must be placed proximal not distal to the bleeding site to effectively restrict arterial flow. Distal placement worsens bleeding and can compromise tissue perfusion unnecessarily.