A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?

Choice A rationale: Donut-shaped cushions are contraindicated because they create a ring of high pressure that restricts blood flow to the central area. This can worsen tissue ischemia and accelerate skin breakdown.

Choice B rationale: Clients with paraplegia sitting in a chair should be repositioned every 15 minutes to relieve pressure. Frequent shifts are necessary because sitting exerts higher pressure on the ischial tuberosities than lying down.

Choice C rationale: Moisture-barrier creams are used to protect skin from incontinence or wound drainage. Nonblanchable erythema indicates a stage 1 pressure injury, which requires pressure relief rather than a topical moisture barrier.

Choice D rationale: While in bed, the standard of care is to turn and reposition the client at least every 2 hours. A 3-hour interval is too long and increases the risk of further tissue damage.

Choice A reason: A heart rate of 60/min is within normal range and does not indicate fluid overload, which may present with tachycardia due to increased cardiac workload. This finding is more consistent with normal physiology or hypovolemia, making it incorrect for identifying fluid overload.
Choice B reason: Skin warm and dry suggests normal hydration or dehydration, not fluid overload, which typically causes edema or moist skin. Dry skin indicates fluid deficit, not excess, making this finding irrelevant and incorrect for assessing fluid overload in this client.
Choice C reason: A respiratory rate of 30/min indicates tachypnea, a sign of fluid overload due to pulmonary edema from excess IV fluids. Fluid in the lungs impairs gas exchange, increasing breathing effort, aligning with clinical manifestations of overload, making this the correct finding.
Choice D reason: Tenting skin turgor indicates dehydration, not fluid overload, as it reflects reduced skin elasticity from fluid loss. Fluid overload causes edema, not tenting, making this finding opposite to the expected presentation and incorrect for this scenario.