A nurse is caring for a client diagnosed with acute rhinosinusitis.

Which of the following instructions should the nurse provide to the client? Select all that apply. 

The correct answer is **d. Monitor the infant for response to auditory stimuli**.

Choice A rationale:

Drawing an antibiotic trough level within 3 days is not a necessary action after a 14-day antibiotic treatment for bacterial meningitis in an infant. Trough levels are typically monitored during the course of treatment to ensure appropriate dosing, not after completion of therapy.

Choice B rationale:

Administering antipyretic medication continuously is not recommended after the completion of antibiotic treatment for bacterial meningitis. Fever is a common symptom during the acute phase of the illness, and the need for antipyretics should decrease as the infection is resolved.

Choice C rationale:

Continuing strict monitoring of daily wet diapers for 1 week is not a necessary action after the completion of antibiotic treatment for bacterial meningitis. Monitoring fluid intake and output is important during the acute phase of the illness, but not necessarily after the infant has completed the full course of antibiotics.

Choice D rationale:

Monitoring the infant for response to auditory stimuli is an important action to include when preparing the family for discharge after a 14-day antibiotic treatment for bacterial meningitis. Hearing loss is a potential complication of bacterial meningitis, and the infant should be evaluated for any hearing impairment before being discharged from the hospital.

Choice A rationale
Low risk: Routine monitoring. This choice is not the most appropriate. While routine monitoring is important for all patients, those receiving the MMR vaccine are not at an increased risk for Venous Thromboembolism (VTE) or Postpartum Hemorrhage (PPH) based solely on the administration of this vaccine.
Choice B rationale
Moderate to high risk: Initiate VTE prophylaxis per policy. This choice is the most appropriate. The risk of VTE and PPH should be evaluated based on the patient’s overall health status, pregnancy history, and current condition. If the patient is determined to be at moderate to high risk, VTE prophylaxis should be initiated per policy.
Choice C rationale
Moderate risk or blood loss greater than 500 mL spontaneous vaginal delivery (SVD) or greater than 1,000 mL cesarean. This choice is not the most appropriate. While these factors can contribute to the risk of VTE and PPH, they are not directly related to the administration of the MMR vaccine.
Choice D rationale
High risk: Greater than 500 mL blood loss SVD or greater than 1,000 mL cesarean, vital sign changes. This choice is not the most appropriate. While these factors can contribute to the risk of VTE and PPH, they are not directly related to the administration of the MMR vaccine.