The nurse continues to care for the client who is at 30 weeks of

Exhibits

Complete the following sentence by using the lists of options.

Based on the client findings, the nurse should first

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and then prepare to administer

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.

A. Bradycardia: Bradycardia is an uncommon response to IV fluid therapy; more frequently, fluid overload can cause tachycardia as the heart attempts to compensate for increased blood volume. Bradycardia would more likely result from other cardiac or neurological issues rather than fluid administration.
B. Weight loss: IV fluid therapy generally results in fluid retention or maintenance of body weight; weight loss is not expected unless there is concurrent fluid loss or other underlying conditions. Monitoring weight gain is important to detect fluid overload rather than weight loss.
C. Distended neck veins: Distended neck veins are a classic sign of fluid volume overload, indicating increased central venous pressure due to excess fluid in the circulatory system. This finding requires prompt intervention to prevent complications such as pulmonary edema or heart failure.
D. Bradypnea: Slow respiratory rate is rarely caused by IV fluids and more commonly indicates neurological impairment, sedation, or respiratory muscle fatigue. It is not a typical adverse effect of fluid therapy and should prompt evaluation for other causes.

A. Tie a tourniquet around the leg distal to the wound: A tourniquet should be placed proximal to the bleeding site to compress major vessels. Placing it distal is ineffective and does not control hemorrhage.
B. Apply direct pressure to the wound with thick dressing material: Applying firm, direct pressure is the most effective initial intervention for external bleeding. It helps reduce blood loss by compressing vessels and encouraging clot formation.
C. Irrigate the wound with sterile water: Irrigating an actively bleeding wound is inappropriate as it may disrupt forming clots and worsen bleeding. Wound cleaning should be done after bleeding is controlled.
D. Apply a transparent dressing to the wound: Transparent dressings are used for clean, non-bleeding wounds. They do not provide the compression or absorption needed for active hemorrhage.