During an assessment of an anxious client diagnosed with right lower lobe pneumonia, the nurse notes a new onset change in mental status and tachypnea. The latest vital signs for the client are T: 98.4 F; HR: 108; RR: 28; BP: 144/90; Pulse ox: 88%. What is the priority nursing action?

Choice a reason:
Placing the client on a 35% Venturi mask would provide a controlled amount of oxygen which is beneficial for clients with chronic obstructive pulmonary disease (COPD) who may retain carbon dioxide. However, this intervention is not directly related to the management of a non-productive cough and difficulty expectorating secretions.

Choice b reason:
Encouraging the client to increase liquid intake throughout the day can help thin the bronchial secretions, making them easier to expectorate. Adequate hydration is essential in the management of chronic bronchitis to help clear mucus from the airways.

Choice c reason:
Administering dextromethorphan, a cough suppressant, may be used to control a non-productive cough. However, it would not assist with the expectoration of secretions and could potentially inhibit the cough reflex needed to clear the airways.

Choice d reason:
Encouraging pursed-lip breathing can help improve ventilation and oxygenation by promoting more effective exhalation. This technique can be beneficial for clients with COPD but does not directly address the issue of expectorating secretions.

Choice A reason:
Administering oxygen using a non-rebreather mask is a subsequent step if initial measures do not improve fetal heart rate decelerations. It can help increase the amount of oxygen available to the fetus. Oxygen administration is a supportive measure that can be used if there are signs of fetal distress. In the scenario described, where the fetal heart rate slows after the start of a contraction with the lowest rate occurring after the peak, it suggests late decelerations, which are often associated with uteroplacental insufficiency. Administering oxygen can help increase the fetal oxygen reserve and is a common intervention during labor when there are concerns about fetal well-being.

Choice B reason:
Increasing the rate of maintenance IV infusion is typically considered when there is a concern for maternal hypotension or dehydration, which may not be the immediate cause of the observed fetal heart rate pattern. Increasing the rate of an IV infusion can help improve maternal hydration and blood pressure, which in turn can enhance placental perfusion. However, this intervention is more indirect and may not provide the immediate response needed to address fetal heart rate decelerations. It is typically considered after more direct interventions, such as repositioning the mother, have been attempted.

Choice C reason:
Elevating the client's legs can help improve venous return to the heart, potentially increasing maternal cardiac output and blood flow to the placenta. While this can be beneficial, it is not the primary intervention for late decelerations. Repositioning the mother to improve uteroplacental circulation is generally the first step.
Choice D reason:
Placing the client in the lateral position is often the first action taken when late decelerations are observed. This position helps improve uteroplacental blood flow and can quickly address potential issues related to fetal oxygenation. This position helps to relieve pressure on the inferior vena cava and aorta, which can be compressed by the gravid uterus, especially in the supine position. Relieving this pressure helps to improve uteroplacental circulation and can quickly address the cause of late decelerations, which is often related to compromised blood flow to the placenta.