A nurse is providing preoperative teaching to an older adult female client who is scheduled for a laminectomy and uses supplements. Which of the following supplements should the nurse identify as increasing the client's risk for hypotension during surgery?

Rationale for correct choices:

• Nephrotic syndrome: The child shows hallmark signs of nephrotic syndrome—periorbital edema, fatigue, frothy urine, hypoalbuminemia (1.4 g/dL), hyperlipidemia (cholesterol 465 mg/dL), massive proteinuria (24 mg/dL), and specific gravity of 2.066. The elevated platelets and ESR also support an inflammatory renal process.
• Administer oral corticosteroids: Corticosteroids like prednisone are the first-line treatment for nephrotic syndrome as they reduce proteinuria by suppressing immune-mediated damage to the glomeruli.
• Encourage a low-sodium diet: A low-sodium diet helps control edema by minimizing fluid retention, which is especially important in children presenting with ascites and periorbital swelling.
• Abdominal girth: Measuring abdominal girth helps track changes in ascites and monitor the effectiveness of fluid management interventions like diet and medication.
• Urine specific gravity: Monitoring urine specific gravity assesses kidney concentration ability and fluid balance. Persistently elevated values may indicate worsening proteinuria or fluid imbalance

Rationale for incorrect choices:

• Acute glomerulonephritis: Although this condition can cause hematuria and edema, it typically follows a streptococcal infection and presents with hypertension, gross hematuria, and low urine output not massive proteinuria or hyperlipidemia.
• Chronic kidney disease: CKD develops over time and is characterized by progressive decline in renal function. This child’s symptoms and labs point more toward an acute or relapsing condition like nephrotic syndrome.
• Hemolytic uremic syndrome: HUS is associated with recent diarrheal illness, thrombocytopenia, anemia, and acute kidney injury—not heavy proteinuria or hypoalbuminemia. Platelet count here is high, not low as seen in HUS.
• Initiate contact precautions: Contact precautions are not routinely required for nephrotic syndrome unless there’s an active infection or immunosuppressive therapy risk—neither of which is indicated in the current scenario.
• Initiate peritoneal dialysis: Dialysis is reserved for end-stage renal disease or severe fluid overload unresponsive to other treatments. The child’s kidney function here, while abnormal, does not yet warrant dialysis.
• Administer antibiotics: There’s no evidence of bacterial infection—no fever, elevated WBC count, or infectious focus. Antibiotics are not appropriate without signs of infection.
• Head circumference: Head circumference is useful in infants for monitoring brain growth but irrelevant in school-age children with kidney disorders.
• Bilirubin: Bilirubin levels assess liver function and jaundice; they’re not relevant in evaluating nephrotic syndrome progression.
• HbA1c: HbA1c measures long-term glucose control in diabetes, not kidney function or protein loss. It's unrelated to the child’s current presentation.

Rationale for Correct Choices:

• Intravenous antibiotic: The client shows multiple signs of endometritis: uterine tenderness, foul-smelling lochia, fever, tachycardia, and elevated WBC count. IV antibiotics are the first-line treatment for postpartum uterine infections, particularly after cesarean delivery with risk factors like prolonged rupture of membranes.
• Increase in daily fluid intake: Clients with infection and fever require increased hydration to support perfusion, manage elevated metabolic demands, and help clear the infection. Fever and poor bowel motility may also contribute to mild dehydration, making fluid support essential.

Rationale for Incorrect Choices:

• Intrauterine tamponade balloon: This is used to control postpartum hemorrhage due to uterine atony or trauma. Although the fundus was boggy, it firmed with massage, and there is no indication of active or excessive bleeding, making tamponade unnecessary.
• Kleihauer-Betke test: This test detects fetal blood in the maternal circulation and is used after trauma or suspected fetal-maternal hemorrhage, especially in Rh-negative mothers. It is not relevant to this postpartum infection scenario.
• Tocolytic medication: Tocolytics are used during pregnancy to suppress preterm labor by relaxing the uterus. In the postpartum period, they are not indicated and would be contraindicated in the presence of infection, as they can reduce uterine tone and worsen involution.