A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions.

Which of the following actions should the nurse take?

Promoting trust involves actions that build a sense of trust and rapport between the nurse and the client. In this scenario, the nurse recognizes the client's basic need for food and responds to it promptly and compassionately. By interrupting the bath to address the client's hunger, the nurse demonstrates attentiveness and care, which helps establish trust between the nurse and the client.

Countertransference refers to the nurse's emotional reaction or response to the client, which may be based on the nurse's personal experiences or unresolved issues. It does not apply to the nurse's action of obtaining a meal for the client.

Veracity refers to truthfulness and honesty. While the nurse's action can be seen as honest and caring, it does not specifically relate to the concept of veracity.

Boundary crossing refers to a situation where the nurse exceeds the established professional boundaries with the client. In this scenario, the nurse's action of obtaining a meal for the client can be seen as a minor deviation from the routine care but is not considered a significant boundary crossing.

Explanation

C. Skin rash with fever

Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening hypersensitivity reaction that can occur as a rare side effect of certain medications, including allopurinol.

Monitoring and early recognition of SJS symptoms are crucial for prompt medical.

Skin rash with fever is a hallmark manifestation of Stevens-Johnson syndrome. It often starts with flu-like symptoms such as fever and malaise, followed by the appearance of a widespread, painful, and rapidly progressing rash. The rash typically involves the mucous membranes, including the mouth, nose, and eyes, and can be accompanied by blisters or sores. Prompt reporting of these symptoms is critical for early diagnosis and intervention.

Tinnitus with ear pain in (option A) is incorrect because it is not typically associated with Stevens- Johnson syndrome. It may indicate another condition or side effect unrelated to SJS.

Hyperreflexia, which refers to abnormally increased reflexes, in (option B) is incorrect because it is not a characteristic manifestation of Stevens-Johnson syndrome. It may indicate a neurological condition or reaction to another medication, but it is not specific to SJS.

Diplopia, or double vision, in option (D) is incorrect because it is not commonly associated with Stevens- Johnson syndrome. It may be caused by other ocular or neurological conditions.

In summary, the nurse should instruct the client taking allopurinol to monitor and report the manifestation of a skin rash with fever. This is important because it may indicate the development of Stevens-Johnson syndrome, a severe and potentially life-threatening reaction to the medication. Early recognition and medical intervention are crucial to minimize complications and ensure appropriate treatment.