A nurse is preparing to administer a dose of digoxin to a client who is experiencing heart failure. Which of the following actions should the nurse take prior to administering this medication?

Rationale for correct choices:

• Deep tendon reflexes 2+ bilaterally: DTRs decreased from 3+ to 2+, indicating reduced hyperreflexia. Hyperreflexia is a hallmark of preeclampsia and HELLP syndrome; improvement suggests that neuromuscular excitability and central nervous system irritability are stabilizing. Monitoring DTRs helps evaluate treatment effectiveness and risk reduction for complications.

• Oxygen saturation (SaO₂) 95% on 2 L nasal cannula: Oxygenation is within acceptable limits for a patient on supplemental oxygen. Maintaining adequate maternal oxygenation supports fetal perfusion and reduces hypoxic stress. Improved oxygen saturation reflects better respiratory status and cardiovascular stability compared with prior readings (SaO₂ 92–94%).

• Respiratory rate 18/min: The client’s respiratory rate is within normal limits, improving from earlier tachypnea (24/min). Stabilization of respiratory rate indicates reduced distress, better oxygenation, and improved overall maternal status, which contributes to safer outcomes for both mother and fetus.

• Blood pressure 146/96 mm Hg: At 1400, the client’s blood pressure had spiked to a very dangerous 170/112 mm Hg (severe hypertension). The decrease to 146/96 mm Hg by 1800 indicates that medical interventions are successfully lowering the pressure toward a safer range.

Rationale for incorrect choices:

• Temperature 38.3° C (101° F): The client’s temperature is elevated, indicating fever. Fever does not reflect improvement and may signal infection, inflammation, or other complications. Ongoing assessment and intervention are required to address the cause of hyperthermia.

• Urine output 40 mL: A single low urine output reading suggests oliguria, which is concerning in preeclampsia or HELLP syndrome. Adequate renal perfusion is essential; this value does not indicate improvement and requires ongoing monitoring.

• Heart rate 58/min: Bradycardia may be related to medications, vagal stimulation, or underlying cardiovascular changes. While it is a change from prior tachycardia, bradycardia itself is not an indicator of improvement and may require further evaluation.

A. Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface: Opening the flap closest to the nurse first increases the risk of contaminating the sterile field. The nurse’s arms and clothing could cross over the field, compromising sterility.

B. Open the side flap of the sterile kit, allowing it to lie flat on the work surface: Side flaps are opened after the flap farthest from the nurse. Opening side flaps prematurely can increase the chance of contaminating the sterile contents.

C. Apply sterile gloves: Sterile gloves are applied after the sterile field has been properly opened and prepared. Donning gloves before opening the sterile kit does not follow the correct sequence of steps.

D. Open the outermost flap of the sterile kit away from the nurse's body: Opening the flap farthest from the nurse first prevents reaching over the sterile field. This action helps maintain sterility and establishes a safe sterile field for the procedure.