A nurse is preparing to insert an IV catheter for a client.
Which of the following actions should the nurse plan to take?

The correct answer is choice c. Swelling of the face.

Choice A rationale:

Urinary frequency is a common symptom during pregnancy, especially in the first and third trimesters, due to hormonal changes and the growing uterus pressing on the bladder. It is generally not a cause for concern unless accompanied by other symptoms like pain or burning during urination, which could indicate a urinary tract infection.

Choice B rationale:

Bleeding gums are also common during pregnancy due to hormonal changes that increase blood flow to the gums, making them more sensitive and prone to bleeding. This condition, known as pregnancy gingivitis, is usually not serious but should be managed with good oral hygiene.

Choice C rationale:

Swelling of the face can be a sign of preeclampsia, a serious condition characterized by high blood pressure and damage to other organs, often the kidneys. Preeclampsia typically occurs after 20 weeks of gestation but can develop earlier. It requires immediate medical attention to prevent complications for both the mother and the baby.

Choice D rationale:

Faintness upon rising, or orthostatic hypotension, is relatively common during pregnancy due to changes in blood circulation. It can usually be managed by rising slowly from a sitting or lying position. However, if fainting is frequent or severe, it should be discussed with a healthcare provider to rule out other underlying conditions.

The correct answer is **a. Observe for bruising of the skin.**

Choice A rationale: Observing for bruising of the skin is an appropriate nursing intervention when caring for a client receiving alteplase (recombinant tissue plasminogen activator or rt-PA), a thrombolytic medication used to dissolve blood clots. Alteplase can increase the risk of bleeding, including bruising, as it works to break down the clot. Closely monitoring the client for any signs of bleeding or bruising is crucial to identify and manage potential complications.

Choice B rationale: Administering medications intramuscularly is not recommended when a client is receiving alteplase. Intramuscular injections can increase the risk of bleeding and should be avoided, as alteplase can impair the body's ability to form clots and stop bleeding.

Choice C rationale: Monitoring vital signs every 4 hours is not the appropriate frequency for a client receiving alteplase. Vital signs should be monitored more frequently, typically every 30 minutes to 1 hour, to closely observe for any changes that may indicate bleeding or other complications.

Choice D rationale: Providing a diet low in protein is not a necessary intervention for a client receiving alteplase. Alteplase works by targeting the blood clot and does not require specific dietary modifications. The focus should be on monitoring for bleeding and managing any potential complications, rather than adjusting the client's diet.