A nurse is providing care to a client who is immunocompromised.
Which of the following should the nurse identify as a possible source of infection?

The correct answer is choice B and C.

Choice A rationale:

Cervical insufficiency is a condition where the cervix begins to shorten and open too early during pregnancy, leading to premature birth or loss of an otherwise healthy pregnancy. However, the client’s symptoms do not indicate cervical insufficiency. There are no reports of lower abdominal pressure, mild pelvic cramps, or a change in vaginal discharge, which are common symptoms of cervical insufficiency.

Choice B rationale:

The client’s severe headache unrelieved by acetaminophen, +3 pitting edema in bilateral lower extremities, and hyperactive reflexes (patellar reflex 4+) are indicative of severe preeclampsia. One of the complications of severe preeclampsia is seizures, also known as eclampsia. Therefore, the client is at risk for developing seizures.

Choice C rationale:

Placental abruption is a serious pregnancy complication in which the placenta detaches from the uterus prematurely. The client’s report of decreased fetal movement could be a sign of placental abruption. In addition, severe preeclampsia can increase the risk of placental abruption. Therefore, the client is at risk for developing placental abruption.

Choice D rationale:

Heart failure occurs when the heart can’t pump enough blood to meet the body’s needs. While preeclampsia can eventually affect many organ systems including the cardiovascular system, there are no immediate signs of heart failure in the client’s symptoms.

Choice E rationale:

Hypoglycemia refers to low blood sugar levels. The client’s symptoms do not suggest hypoglycemia. Symptoms of hypoglycemia typically include confusion, dizziness, feeling shaky, hunger, headaches, irritability, pounding heart or irregular heartbeat, sweating, trembling or tremors, and weakness. In conclusion, based on the client’s symptoms and clinical presentation, she is at greatest risk for developing seizures (Choice B) and placental abruption (Choice C) due to severe preeclampsia.

Following a subtotal thyroidectomy, the nurse should position the client in a way that minimizes strain on the surgical site and promotes respiratory function. The most appropriate position for this client is:

d) Semi-Fowler's.

Semi-Fowler's position, where the head of the bed is elevated at a 30 to 45-degree angle, helps reduce swelling at the surgical site and facilitates breathing. This position also minimizes tension on the suture line and aids in preventing strain on the neck.

The other options are not as suitable for post-thyroidectomy positioning:

a) Dorsal recumbent: This position involves lying on the back with the knees flexed. While it might be used in some situations, it doesn't specifically address the considerations after a thyroidectomy.

b) Supine: Lying flat on the back may not provide optimal support to the neck and could potentially increase discomfort.

c) Left lateral: Lying on the left side may not be as effective in reducing strain on the neck and surgical site compared to the semi-Fowler's position.