A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority?

Rationale:

A. The nurse should dispose of the ampule in the trash can: Glass ampules are considered sharps and must be disposed of in a designated sharps container to prevent injury and maintain safety. Throwing them in regular trash is unsafe and violates standard precautions.

B. The nurse should use the same needle to draw up and inject the client: Using the same needle can introduce glass particles or contamination into the client’s tissue. A new sterile needle should be used for injection after withdrawing the medication to ensure safety and sterility.

C. The nurse should use a filter needle to withdraw the medication: A filter needle is designed to prevent small glass shards from being drawn into the syringe when breaking the ampule. This action protects the client from injury and ensures that the medication administered is free from particulate matter.

D. The nurse should break the neck of the ampule toward their body: The ampule should always be broken away from the body to prevent injury from glass shards. Breaking it toward oneself increases the risk of cuts and contamination, making it an unsafe practice.

Rationale:

• Measure the infant's weight daily: Daily weight monitoring is standard for postoperative infants to assess hydration status and overall recovery. Accurate weight helps guide fluid replacement and nutrition management.

• Initiate short breastfeeding sessions 12 hr postoperatively: Postoperative feedings usually begin relatively quickly (often 4-6 hours post-op) with small amounts of clear fluids or breast milk/formula, gradually increasing. 12 hours is an expected time frame to begin re-feeding/breastfeeding sessions.

• Place the infant in prone position after feeding: Infants are placed on their backs (supine) to reduce the risk of sudden infant death syndrome (SIDS). Prone positioning after feeding is not recommended in postoperative care unless specifically ordered for surgical reasons.

• Fold the infant's diaper below the incision site: Keeping the diaper below the surgical site prevents irritation, friction, or pressure on the incision, promoting healing and preventing infection. This is a standard nursing intervention after abdominal surgery in infants.