The nurse continues to care for the client.

Exhibits

The nurse administers the client's scheduled medication. Which of the following adverse effects of the medication should the nurse monitor the client for? Select all that apply.

Rationale:

A. Instruct the client to shower and change their clothes: The client should avoid bathing, showering, changing clothes, eating, or drinking before a forensic examination. These actions can destroy vital evidence needed for legal and medical purposes.

B. Ask the client for details about the assault: While the nurse should provide emotional support and allow the client to speak if they choose, probing for details can be retraumatizing. A trained forensic examiner should conduct this interview in a sensitive and structured manner.

C. Reassure the client that their injuries are not life threatening: While reassurance is important, making assumptions about the severity of injuries can invalidate the client’s emotional trauma. The nurse should focus on safety, stabilization, and support.

D. Limit the number of staff members providing care for the client: Reducing the number of caregivers helps minimize overstimulation, preserves privacy, and creates a sense of control and safety for the client. This trauma-informed approach is essential in early post-assault care.

Rationale:

A. Provide a low-stimulation environment: The client has a severe headache, 3+ proteinuria, and elevated BP, indicating severe preeclampsia. A quiet, low-light environment reduces the risk of seizure by limiting neurologic stimulation.

B. Maintain bed rest: Bed rest in a side-lying position improves uteroplacental blood flow and helps lower blood pressure. It also decreases metabolic demand, which is critical in hypertensive pregnancies.

C. Give antihypertensive medication: The BP readings (162/112 and 166/110 mm Hg) require immediate antihypertensive therapy to prevent cerebral hemorrhage, eclampsia, or placental abruption.

D. Obtain a 24-hr urine specimen: A 24-hour urine collection for protein is the gold standard for quantifying proteinuria and confirming the diagnosis of preeclampsia. While a dipstick of 3+ is a strong indicator, the 24-hour collection provides a definitive measurement.

E. Perform a vaginal examination every 12 hr: There are no contractions or signs of labor, so regular vaginal exams are not indicated and increase the risk of infection in a preterm pregnancy.

F. Monitor intake and output hourly: Decreased renal perfusion is a complication of preeclampsia. Hourly monitoring detects oliguria early and helps assess for fluid overload or worsening renal function.

G. Administer betamethasone: At 31 weeks, betamethasone is indicated to enhance fetal lung maturity due to risk of preterm delivery from severe maternal complications.