A nurse manager is teaching a newly licensed nurse about pain management for an older adult client. Which of the following statements by the nurse indicates an understanding of the teaching?

Rationale:

A. Insert the catheter into the foot: While the scalp and foot veins may be used in infants, foot veins are less preferred in mobile infants due to the risk of dislodgement. Site selection should prioritize accessible and secure veins, often in the hand or scalp.

B. Obtain a 24-gauge catheter: A 24-gauge catheter is the appropriate size for infants due to their small and delicate veins. It minimizes trauma during insertion and allows for adequate flow while reducing the risk of vein damage.

C. Use gauze to cover the IV insertion site: Transparent dressings, not gauze, are preferred for covering IV sites in infants. They allow for continuous visualization of the site to detect signs of infiltration or infection promptly.

D. Monitor the IV site every 8 hours: IV sites in infants should be monitored much more frequently due to their higher risk of infiltration, dislodgement, or phlebitis. Hourly monitoring is standard practice, especially in high-acuity or pediatric settings.

Rationale for Correct Choices:

• Seizures: The client presents with severe preeclampsia, indicated by BP >160/110 mm Hg, 3+ proteinuria, hyperreflexia (patellar reflex 4+), and persistent headache. These are strong predictors of progression to eclampsia, which is marked by seizures.
• Placental Abruption: Severe hypertension increases the risk of placental abruption due to vascular compromise in the uteroplacental circulation. Decreased fetal movement may be an early warning sign of impaired placental perfusion or separation.

Rationale for Incorrect Choices:

• Cervical Insufficiency: This is a painless cervical dilation often leading to second-trimester loss, unrelated to hypertension or proteinuria. The client is in the third trimester with no signs of cervical changes.
• Hypoglycemia: The client has no history of diabetes, glucose intolerance, or related symptoms. Her urine glucose was only trace, and no medications suggest insulin use.
• Heart Failure: No signs of pulmonary congestion, dyspnea, or elevated heart rate are present. Oxygen saturation is normal, and breath sounds are not mentioned as abnormal, making CHF unlikely at this stage.