A nurse is assisting with the care of a client

Exhibits

Select the 3 findings that require immediate follow-up.

Rationale:

• Monitor fetal heart rate: Continuous monitoring is essential after epidural placement to detect changes in fetal status. Minimal variability and early decelerations could indicate emerging fetal distress. Early detection guides timely intervention.

• Assist with administration of ampicillin IV: The client is GBS positive and in active labor with ruptured membranes. IV antibiotics reduce the risk of neonatal infection. Prompt administration is key for prophylaxis.

• Request a prescription for ephedrine: Epidural anesthesia may cause maternal hypotension, which decreases placental perfusion. Ephedrine helps maintain blood pressure. This supports uteroplacental circulation and fetal oxygenation.

• Place the client in left lateral position: This improves uterine perfusion and helps relieve vena cava compression. It is especially important after epidural anesthesia. It also supports better fetal oxygenation during decelerations.

• Decrease the IV flow rate: IV fluids help counteract hypotension that may result from epidural use. Reducing the rate would worsen perfusion and blood pressure. This could compromise fetal oxygen delivery.

Rationale:

A. Thoroughly explain each procedure to the toddler: Toddlers have limited cognitive ability to understand detailed explanations. Overexplaining may cause anxiety rather than reassurance, especially if unfamiliar medical terms are used.

B. Allow the toddler to handle the equipment: Allowing the toddler to touch and explore safe medical equipment, like a stethoscope, helps reduce fear and builds trust. This play-based approach fosters cooperation and makes the exam less intimidating.

C. Completely undress the toddler: Toddlers can feel vulnerable when fully undressed. It is more appropriate to remove clothing gradually, only as needed for each part of the examination, to ensure comfort and security.

D. Start the examination with routine immunizations: Beginning with painful procedures like injections can create fear and resistance, making the rest of the exam more difficult. Immunizations should be done at the end of the visit.