A nurse is reinforcing teaching with a guardian about receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse include as a potential effect of the medication?

A. A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for: This is appropriate documentation practice. Nurses are responsible for documenting client information in the EMR when they provide direct care, ensuring accurate and timely records.

B. A nursing colleague printing material that does not contain identifiable information from a client's electronic medical record (EMR) for professional use: If no identifiable client information is included, and it is for professional, educational, or training purposes, this action is acceptable and does not violate confidentiality.

C. A nursing colleague discussing a client's diagnosis with another staff member on the unit who is not involved in the client's care: Discussing confidential client information with staff not directly involved in the client's care is a violation of HIPAA and breaches client privacy. Only staff responsible for the client's care should access or discuss their health information.

D. A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report: This is appropriate because handoff reports ensure continuity of care. Discussing necessary client information with the next caregiver is essential for safe, effective client management.

• Deep tendon patellar reflex: The client's deep tendon reflexes improved from being hyperreflexive at 4+ to normal at 2+ without clonus on Day 2. This is a positive sign because hyperreflexia increases seizure risk in preeclampsia, and normalization indicates stabilization of neurological irritability.
• Blood pressure: Although still elevated, the blood pressure decreased from 166/110 mm Hg to 152/90 mm Hg by Day 2. While not normal yet, the trend toward lower values represents improvement in controlling the severe hypertension associated with preeclampsia.
• Heart rate: The client's heart rate increased slightly from 72/min to 90/min. While still within normal range, this change reflects a more responsive and stable cardiovascular status, and there are no signs of bradycardia or distress, supporting mild improvement.
• Edema: The client continues to have +3 pitting edema bilaterally, with no reported reduction compared to the initial assessment. Persistent severe edema suggests that fluid balance issues from preeclampsia have not yet improved and still require active management.