A nurse is assisting in the care of a client on a labor and delivery unit.

Exhibits

Which of the following findings require further evaluation by the nurse?

Select all that apply.

A. Prepare the client for a chest x-ray to verify catheter placement. A chest x-ray is required after central venous catheter insertion to confirm proper placement before initiating total parenteral nutrition (TPN). Incorrect placement can lead to complications such as pneumothorax, arterial puncture, or catheter malposition, making verification essential for safe administration.
B. Use clean technique when changing the catheter dressing. Central venous catheter dressings require sterile technique, not clean technique, to prevent bloodstream infections. Proper infection control measures, including hand hygiene, chlorhexidine skin antisepsis, and sterile gloves, help minimize the risk of catheter-related bloodstream infections.
C. Verify the amount of TPN solution the client is receiving every 4 hr. TPN is typically monitored continuously, with infusion rates checked at least hourly to ensure proper administration. Regular assessments of fluid balance, glucose levels, and electrolyte status are also necessary to prevent complications such as hyperglycemia or fluid overload.
D. Place the client in Sims' position for catheter insertion. The preferred position for central venous catheter insertion is Trendelenburg or supine, which helps dilate the veins and reduces the risk of air embolism. Sims’ position (lying on the left side with the right knee flexed) is not appropriate for this procedure.

A. Neck pain can occur in some patients following electroconvulsive therapy (ECT) due to muscle tension or positioning during the procedure. However, it is not a common or expected adverse reaction associated with ECT, so it is not the primary concern to address.
B. Temporary memory loss is a well-documented adverse reaction following ECT. Patients may experience difficulties with short-term memory, particularly related to events that occurred around the time of the treatment. This memory loss is usually temporary, but it can be distressing for some individuals.
C. Voice alteration is not typically associated with ECT. Although some patients may experience hoarseness or changes in vocal quality due to intubation or anesthesia, this is not a direct result of ECT itself and is not commonly mentioned in the context of ECT side effects.
D. Tingling of the scalp is not a recognized adverse reaction to ECT. Patients may experience various sensations, but tingling is not a common or documented response. The primary focus should be on more significant effects, such as temporary memory loss and potential confusion immediately following the treatment.