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. "I can continue my current alcohol intake." The client should avoid alcohol while taking tuberculosis (TB) medications such as isoniazid and rifampin, as alcohol increases the risk of hepatotoxicity.
B. "I can expect my contact lenses to turn red or orange." Rifampin, a common medication used to treat TB, can cause bodily fluids such as urine, sweat, tears, and saliva to turn red or orange. This can stain soft contact lenses permanently, so clients should be informed of this side effect.
C. "I will need to take my medications for a total of 6 weeks." The standard treatment for TB typically lasts at least 6 months, not just 6 weeks. Clients must complete the full course of therapy to prevent drug resistance and recurrence.
D. "I will need to have a repeat Mantoux test in 4 weeks." A Mantoux test (tuberculin skin test) is not needed after a confirmed TB diagnosis with a positive sputum culture. Instead, follow-up evaluations include repeat sputum cultures and chest x-rays.
E. "I am no longer contagious." Clients with active pulmonary TB are considered contagious until they have completed at least two weeks of effective treatment, have improving symptoms, and have three consecutive negative sputum cultures.
F. "I should notify my provider if I start taking new over-the-counter or prescription medications." TB medications, especially rifampin, can interact with many drugs, including oral contraceptives, anticoagulants, and antiretrovirals. Clients must inform their provider of any new medications.
G. "I will need to have someone observe me when I take medication." Directly observed therapy (DOT) is recommended for clients with TB to ensure medication adherence and reduce the risk of treatment failure or drug resistance.

A. Diminished hearing. Hearing loss following a stapedectomy is expected due to postoperative swelling, packing in the ear, and fluid accumulation. Hearing typically improves as healing progresses. This does not require further action by the nurse.
B. Pupils. The preoperative and postoperative pupil assessments are similar (3.5 mm preoperatively and 3 mm postoperatively), and both are equal and reactive to light. No significant neurological change is noted, so this does not require further action.
C. Lung assessment. The lungs were clear bilaterally preoperatively, and there is no indication of respiratory compromise or abnormal lung sounds postoperatively. This does not require further action.
D. Facial nerve assessment. Facial nerve injury (cranial nerve VII dysfunction) is a potential complication of stapedectomy. The nurse should assess for asymmetry in facial movements such as difficulty smiling or drooping, weakness, or numbness, which could indicate facial nerve damage. This requires further action.
E. Vertigo. Postoperative vertigo and dizziness can occur due to disturbance of the inner ear during surgery. Severe or persistent vertigo may indicate labyrinthine injury or perilymph fistula, which could require medical intervention. This requires further action.
F. Pain rating. Postoperative pain is expected, but severe or increasing pain may indicate complications such as infection, excessive pressure in the middle ear, or improper prosthesis placement. Pain that is not relieved by analgesics requires further evaluation. This requires further action.