A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth?

Choice A rationale:

Documenting the client's vital signs obtained by an assistive personnel is correct. Documenting vital signs is fundamental and immediate requirement when admitting a client to ensure their current health status is accurately captured and can be monitored effectively.

Choice B rationale:

Charting a summary of the data at the change of the shift is incorrect. While it's essential to provide an update at shift change, this option suggests summarizing the data, which might not include all necessary details. Comprehensive documentation is crucial for continuity of care and accurate communication among healthcare providers. Documenting specific vital signs, assessments, interventions, and the client's response to those interventions is necessary for effective patient care.

Choice C rationale:

Noting whether the client has a living will is incorrect. While it's essential to be aware of a client's advanced directives, this information is typically gathered during the admission process or during routine assessments. It is not the immediate action to be taken upon admission. Vital signs and other immediate clinical data take precedence during the initial documentation process.

Choice D rationale:

Beginning charting with an evaluation of the data is incorrect. It is important to document objective data, such as vital signs, observations, and assessments, before making any evaluations or interpretations. Objective data provide the basis for clinical decisions and interventions. Starting with evaluations might lead to biased documentation, potentially overlooking important clinical findings.

- A. The nurse should discourage raw fruits due to risk of infection.

- B. There is no standard recommendation against exposure to young children.

- C. Incorrect. The nurse should measure the client's temperature at least every 4 hr, or more frequently if indicated because fever is a sign of infection in a client who has neutropenia and requires prompt intervention.

- D. Incorrect. The nurse should use disposable gloves from a box inside the client's room, not outside, to prevent cross-contamination and protect the client from exposure to pathogens.