A nurse is providing teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching?

Rationale

A. Perform a vaginal examination every 12 hr: Vaginal examinations should be avoided in a client with severe preeclampsia unless delivery is imminent, as they can stimulate uterine activity and increase the risk of placental abruption. Continuous monitoring and noninvasive assessments are prioritized instead.

B. Administer betamethasone: Betamethasone promotes fetal lung maturity by stimulating surfactant production when preterm delivery before 34 weeks is anticipated. This reduces the risk of neonatal respiratory distress syndrome and intraventricular hemorrhage.

C. Provide a low-stimulation environment: A quiet, dimly lit environment helps minimize CNS stimulation, reducing the risk of seizure activity in clients with severe preeclampsia. Environmental stressors such as bright lights and loud noises should be avoided.

D. Maintain bed rest: Bed rest, particularly in the left lateral position, improves uteroplacental perfusion and reduces blood pressure by minimizing pressure on the vena cava. It also helps limit activity that could elevate BP further.

E. Obtain a 24-hr urine specimen: Collecting a 24-hour urine specimen allows accurate assessment of total protein excretion, which confirms the severity of preeclampsia. Proteinuria greater than 300 mg/24 hr indicates significant renal involvement.

F. Give antihypertensive medication: Antihypertensives such as labetalol or hydralazine help prevent maternal complications like stroke or heart failure from sustained severe hypertension while avoiding excessive BP reduction that could impair uteroplacental blood flow.

G. Monitor intake and output hourly: Close monitoring of intake and output detects early signs of renal compromise or fluid overload, which are common in preeclampsia. Accurate measurement helps guide safe fluid management and prevent pulmonary edema.

Rationale:
A. Ask an experienced nurse to assist with the procedure: Seeking assistance from an experienced nurse promotes patient safety and supports proper skill development. The newly licensed nurse can observe, perform the procedure under supervision, and ensure that the client receives competent care while staying within professional practice boundaries.

B. Delegate the task to an assistive personnel: Tracheal suctioning is a sterile and invasive procedure that requires nursing judgment and assessment, which are outside the scope of practice for assistive personnel.

C. Identify that the task is in the scope of RN practice and perform the suctioning: Although tracheal suctioning is within an RN’s scope, the nurse should not perform it independently without adequate training or supervision.

D. Refuse to take the assignment: Refusing the assignment entirely is inappropriate because the nurse has a duty to provide care within their level of competence. Instead, the nurse should seek guidance and supervision to safely complete the procedure.