A nurse is caring for a client who has a newly created colostomy. The client’s partner tells the nurse that the client refuses to look at the stoma. Which of the following actions should the nurse take?

Choice A reason: Keeping the drainage bag above waist level promotes urine backflow, increasing infection risk. Bags must be below bladder level to ensure proper urine flow, so this action is incorrect and unsafe, requiring nurse intervention.
Choice B reason: Disconnecting the catheter to empty the bag breaks the closed system, increasing infection risk. The bag should be emptied via the drainage port, so this action is incorrect and requires correction by the nurse.
Choice C reason: Emptying the drainage bag when three-quarters full prevents overfilling, reducing backflow and infection risk. This aligns with proper catheter care protocols, ensuring safety for a fall-risk client, making it the correct technique.
Choice D reason: Using sterile gloves for emptying the drainage bag is unnecessary, as clean gloves suffice for this non-sterile procedure. Sterile gloves are for catheter insertion, so this action is incorrect and inefficient, requiring guidance.

Choice A reason: Referring to a mental health clinic addresses potential emotional distress but not the adolescent’s primary concern of affordability. Pregnancy increases psychological stress, but financial barriers to prenatal care are critical. This action fails to ensure access to medical resources, essential for maternal and fetal health in adolescent pregnancy.
Choice B reason: Contacting the adolescent’s parent risks breaching confidentiality, depending on legal guidelines, and does not address financial concerns directly. Family dynamics may complicate support, and without consent, this action could increase stress, failing to provide immediate healthcare access critical for a healthy pregnancy outcome.
Choice C reason: Assisting with Medicaid application directly addresses financial concerns, ensuring access to prenatal care, delivery, and postpartum support. Medicaid reduces risks like preterm birth by covering medical and nutritional needs, critical for adolescent mothers with limited resources, aligning with public health goals for maternal-fetal well-being.
Choice D reason: Advising adoption is premature and overlooks the adolescent’s autonomy. Adoption requires extensive counseling, not immediate recommendation. It fails to address healthcare access, critical for a healthy pregnancy. This approach dismisses financial solutions, potentially increasing stress and undermining informed decision-making in pregnancy.