The nurse continues to care for the client.

A nurse on the inpatient mental health unit is planning care for the client.

For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client.

A. Administer betamethasone: Betamethasone is indicated to promote fetal lung maturity in a client at 31 weeks gestation at risk for preterm delivery. Administering corticosteroids reduces neonatal complications and is appropriate for this high-risk pregnancy.

B. Give antihypertensive medication: The client’s blood pressure readings (162/112 mm Hg and 166/110 mm Hg) indicate severe hypertension, which requires prompt management to prevent maternal complications such as stroke, eclampsia, or organ damage. Administering antihypertensives is a priority in controlling blood pressure.

C. Monitor intake and output hourly: Frequent monitoring of fluid balance is essential due to the risk of renal impairment from preeclampsia. Hourly intake and output helps detect oliguria or fluid retention, which can indicate worsening maternal status or impending complications.

D. Perform a vaginal examination every 12 hr: Routine vaginal examinations are avoided in clients with preeclampsia or severe hypertension due to the risk of inducing labor or causing trauma. Vaginal exams should be performed only when medically indicated.

E. Obtain a 24-hr urine specimen: Measuring proteinuria via a 24-hour urine collection helps evaluate the severity of preeclampsia and guides clinical management. This client has 3+ protein on urinalysis, confirming significant proteinuria.

F. Provide a low-stimulation environment: Reducing stimuli helps prevent exacerbation of headache, hypertension, and risk for seizures. A calm, quiet environment is a standard intervention for clients with severe preeclampsia.

G. Maintain bed rest: Bed rest with lateral positioning promotes uteroplacental perfusion, reduces blood pressure, and helps prevent complications such as eclampsia. The intervention supports maternal and fetal stability in the acute phase of severe preeclampsia.

A. "If a client is gravely disabled, they may request admission as a voluntary individual.": Clients who are gravely disabled typically cannot make informed decisions regarding their care, so they would not be eligible for voluntary admission. Voluntary admission requires the client to have the capacity to consent to treatment.

B. "If a client under voluntary admission requests to leave, the nurse should contact the provider.": Clients admitted voluntarily have the right to request discharge, but the nurse must notify the healthcare provider to ensure safe discharge planning and evaluate if any legal or medical concerns exist. This statement reflects correct understanding of the legal responsibilities in voluntary admissions.

C. "Clients are not required to complete an admission application for voluntary admission.": Voluntary admission generally requires completion of an admission application or consent form to document the client’s agreement to treatment. Omitting this step would not comply with legal or institutional requirements.

D. "Clients under the age of 16 require involuntary commitment rather than voluntary admission.": Minors can be admitted voluntarily with parental or guardian consent depending on state law. They do not automatically require involuntary commitment, so this statement reflects a misunderstanding of the regulations surrounding voluntary admission of minors.