A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections.
Which of the following instructions should the nurse include in the teaching?

The correct answer is choice A, B, D, and F.

Choice A rationale:

The presence of protein in the urine (proteinuria) is a sign of potential prenatal complication. Normally, urine should be protein negative. Proteinuria can be a sign of preeclampsia, a serious condition that includes high blood pressure and swelling, and can lead to preterm birth or other serious complications if not managed.

Choice B rationale:

The client’s blood pressure is 162/112 mm Hg, which is significantly higher than the normal range (less than 120/80 mm Hg). High blood pressure during pregnancy could indicate preeclampsia or other complications.

Choice C rationale:

The client’s respiratory rate is 16/min, which falls within the normal range (12-20 breaths per minute). Therefore, it does not indicate a potential prenatal complication.

Choice D rationale:

The client’s report of a severe headache unrelieved by acetaminophen is concerning. This could be a symptom of preeclampsia or other serious conditions and should be investigated further.

Choice E rationale:

The client’s gravida/parity (G3 P2 with one preterm birth) does not directly indicate a potential prenatal complication. However, a history of preterm birth could put the client at higher risk for another preterm birth.

Choice F rationale:

The client’s report of decreased fetal movement is concerning. Decreased fetal movement can be a sign of fetal distress or other complications and should be investigated further.

Choice G rationale:

The client’s urine does not contain ketones, which would indicate that the body is using fat for energy instead of glucose. This could occur in cases of poor nutrition or gestational diabetes. Since the urine is ketone negative, this does not indicate a potential prenatal complication.

The correct answer is choiceA. Lift the penis so that it is perpendicular to the client’s body.

Choice A rationale:

Lifting the penis so that it is perpendicular to the client’s body straightens the urethra, making it easier to insert the catheter without causing trauma.

Choice B rationale:

While cleansing the tip of the penis in a circular motion is important for maintaining aseptic technique, it is not the specific action that facilitates the insertion of the catheter.

Choice C rationale:

Picking up the catheter 13 cm (5 in) from its tip is not a standard practice.The nurse should hold the catheter closer to the tip to maintain control and ensure accurate insertion.

Choice D rationale:

Inflating the catheter balloon before insertion can cause trauma to the urethra and is not recommended.The balloon should only be inflated once the catheter is correctly positioned in the bladder.