A nurse on a postpartum unit is caring for a client.

Exhibits

The nurse should anticipate a provider's prescription for a(n)

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and

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.

Rationale:

A. I should clean my stoma with moisturizing soap: Moisturizing soaps can leave a residue that interferes with the adhesive of the pouching system. The stoma area should be cleaned with warm water or a mild, non-moisturizing soap to ensure the pouch adheres properly.

B. I should cut my pouch opening 1/8 inch larger than my stoma: The opening should be just slightly larger than the stoma about 1/8 inch to prevent constriction while still protecting the surrounding skin from effluent and minimizing skin irritation.

C. I should expect my stoma to be blistered: A healthy stoma should appear moist, pink or red, and smooth. Blistering is a sign of skin breakdown or irritation and indicates improper pouch fitting or leakage, which requires intervention.

D. I should change my stoma pouch 30 minutes after heals: There isn't a specific 30-minute post-meal rule. The most important guideline for changing a pouch is when it's about one-third to one-half full, or if there is leakage or discomfort.

Rationale for Correct Choices:

• Evaluating the fetal heart rate tracing: The client’s report of decreased fetal movement and severe hypertension raises concern for fetal compromise. Immediate fetal assessment ensures the fetus is tolerating the intrauterine environment, especially before administering medications like magnesium sulfate.
• Administering magnesium sulfate IV: This is prescribed to prevent eclampsia, given the client’s severely elevated BP, hyperreflexia, and proteinuria. After confirming fetal status, seizure prophylaxis should be initiated without delay.

Rationale for Incorrect Choices:

• Administering acetaminophen PO: Although ordered for headache, the symptom is a manifestation of severe preeclampsia. Treating it symptomatically without addressing its cause could delay necessary critical interventions.
• Obtaining a 24-hour urine collection: Useful for confirming the extent of proteinuria, but not immediately necessary for clinical decision-making given existing positive findings.
• Inserting an indwelling urinary catheter: This supports fluid monitoring during magnesium therapy, but fetal assessment and seizure prevention take precedence.
• Administering betamethasone IM: Important for fetal lung development in preterm pregnancies, but it is not the immediate priority when there is a high risk for seizure or fetal distress.