The nurse is continuing to care for the client.

Nurses' Notes.

Day 1, 0900:. Day 1, 0930:. Client is at 31 weeks of gestation and presents with a severe.

headache unrelieved by acetaminophen.

Client also reports.

urinary frequency and decreased fetal movement.

Client is a G3. P2 with one preterm birth.

Client reports a constant and throbbing headache and rates it. as a 6 on a scale of 0 to 10. Denies visual disturbances.

+3. pitting edema in bilateral lower extremities.

Patellar reflex 4+. without the presence of clonus.

Client reports occasional.

nighttime leg cramps.

Reports three fetal movements within the.

last 30 min.

External fetal monitor applied with a baseline FHR.

140/min with occasional accelerations and moderate variability.

No uterine contractions noted.

Vital Signs.

Day 1, 0900:. Temperature (oral) 36.9° C (98.4° ). Heart rate 72/min.

Respiratory rate 16/min.

BP 162/112 mm Hg. Oxygen saturation 979% on room air.

Day 1, 0930:. Temperature (oral) 37.1° C (98.8° ). Heart rate 84/min.

Respiratory rate 18/min.

BP 166/110 mm Hg. Oxygen saturation 999% on room air.

Color yelow yelow). pH 5.9 (4.6 to 8). Protein 3+ (negative). Specific gravity 1.013 (1.005 to 1.03). Leukocyte esterase negative (negative). Nitrites negative (negative). Ketones negative (negative). Crystals negative (negative). Casts negative (negative). Glucose trace (negative). WBC 5 (0 to 4). WBC casts none (none). RBC 1 (less than or equal to 2). RBC casts none (none). Day 1, 1030:. CBC:. Hemoglobin 18.0 g/dL (12 to 16 g/dL). Hematocrit 35% (37 to 479%). Platelets 98,000/mm³ (150,000 to 400,000/mm³). BUN 19 mg/dL (10 to 20 mg/dL). Creatinine 0.8 mg/dL (0.5 to 1 mg/d). WBC 8,000/mm³ (5,000 to 10,000/mm³). Glucose 85 mg/dL (74 to 106 mg/dL). Liver Enzymes:. Alanine aminotransferase (ALT) 40 units/L (4 to 36 units/L). Aspartate aminotransferase (AST) 42 units/L (0 to 35 units/L). Total bilirubin 1.2 mg/dL (0.3 to 1 mg/dL). The nurse is reviewing the assessment findings.

For each assessment finding, click to specify if the finding is consistent with.

preeclampsia or HELLP syndrome.

Each finding may support more than one.

disease process.

Choice A rationale:

Recording the client's progress in the nurses' notes is important for documentation but does not directly promote communication among staff caring for the client. It is essential for the continuity of care and legal documentation, but it does not facilitate active communication between team members.

Choice B rationale:

Posting swallowing precautions at the head of the client's bed is essential for the client's safety, especially considering the risk of aspiration following a stroke. While it ensures the staff is aware of the precautions, it does not directly promote communication among the staff members.

Choice C rationale:

Having interdisciplinary team meetings for the client on a regular basis is the best choice as it promotes communication among the staff caring for the client. Interdisciplinary team meetings allow healthcare professionals from various disciplines, such as nurses, therapists, and doctors, to collaborate, share information, and discuss the best approach to care for the client. This approach ensures comprehensive and coordinated care, addressing both the client's medical and communication needs.

Choice D rationale:

Noting changes in the treatment plan in the client's medical record is crucial for documentation and continuity of care but does not actively promote real-time communication among the staff members. While it is essential for keeping the medical record updated, it does not facilitate immediate communication and collaboration between healthcare professionals.

Choice A rationale:

Making decisions about health care on clients' behalf without their involvement violates the principle of patient autonomy. Patients have the right to be actively involved in decisions about their own care and treatment plans. Encouraging shared decision-making and respecting patients' choices are essential aspects of nursing advocacy.

Choice B rationale:

Promoting health care access is a fundamental aspect of advocacy in client care. Nurses should advocate for their patients' access to necessary healthcare services, treatments, and resources. This includes ensuring that patients have access to appropriate medical facilities, specialists, medications, and therapies. Advocating for health care access helps patients receive timely and appropriate care, improving their overall health outcomes.

Choice C rationale:

Encouraging clients to seek further information from the provider is crucial for informed decision-making. Providing patients with accurate and relevant information enables them to make educated choices about their health. Nurses can facilitate this process by clarifying medical information, explaining treatment options, and addressing patients' concerns. Informed patients are better equipped to actively participate in their care and advocate for their own needs.

Choice D rationale:

Addressing client needs when providing resources is an essential aspect of nursing advocacy. Nurses should assess their patients' individual needs and collaborate with other healthcare professionals to provide appropriate resources and support. This can include coordinating social services, arranging for home healthcare, or connecting patients with support groups. Meeting clients' needs ensures that they receive comprehensive care, promoting their overall well-being.

Choice E rationale:

Honoring family requests to withhold medical information can be ethically challenging. While family members play a significant role in a patient's life, confidentiality and patient autonomy must be respected. In most cases, healthcare providers should prioritize communicating directly with the patient, respecting their right to make decisions about their own health information. Exceptions may arise in situations involving legal guardianship or when patients are unable to communicate their preferences. However, the default approach should be to involve the patient directly in decisions about their healthcare information.