A nurse is caring for a client who has major depressive disorder and is refusing their medication. The client's family suggests placing the client's medication in their food. Which of the following actions should the nurse take?

a. "The machine is programmed to prevent you from administering more than a safe dose."

When reinforcing teaching about epidural PCA (patient-controlled analgesia) with a client in active labor, it is important for the nurse to inform the client about the safety features of the machine. By explaining that the machine is programmed to prevent the client from administering more than a safe dose, the nurse reassures the client that they have control over their pain relief while minimizing the risk of overdose.

Option b, "During medication administration, you will not be able to move your legs freely," is not an accurate statement regarding epidural PCA. While epidural analgesia may cause temporary weakness or loss of sensation in the lower body, the ability to move the legs freely is not necessarily completely impaired. The degree of mobility can vary depending on the dosage and specific characteristics of the epidural.

Option c, "This method of pain control will shorten the second stage of labor," is not a valid statement. Epidural PCA is primarily used for pain relief during labor and delivery but does not directly affect the progression or duration of the second stage of labor, which involves pushing and the delivery of the baby.

Option d, "This type of anesthesia commonly causes a postpartum headache," is also incorrect. While headaches can occur as a potential side effect of epidural anesthesia, they are not specifically associated with epidural PCA. Postpartum headaches can have various causes and are not exclusively related to the use of epidural PCA.

By emphasizing the safety features of the machine and explaining that it prevents the administration of excessive doses, the nurse ensures that the client understands the appropriate use of the epidural PCA for pain control during labor.

The correct answer is b. "I will apply petroleum jelly to the penis with each diaper change."

Choice A rationale:

• It is incorrect to focus on removing all yellow exudate.A small amount of yellow exudate is normal during the healing process after circumcision.Attempting to aggressively clean it off can irritate the delicate healing tissues and cause discomfort for the baby.
• Instead,parents should gently cleanse the area with warm water during diaper changes,allowing any mild exudate to naturally drain.

Choice B rationale:

• Applying petroleum jelly with each diaper change is an essential step in promoting healing and preventing discomfort after circumcision.Here's why:
  • Protects against moisture:Petroleum jelly forms a barrier that protects the delicate healing tissues from moisture from urine and feces.This helps to prevent irritation and keeps the area clean.
  • Reduces friction:The lubricating properties of petroleum jelly reduce friction between the penis and the diaper,which can minimize discomfort and pain for the baby.
  • Promotes healing:Petroleum jelly creates a moist environment that promotes healing and reduces scab formation.This helps the circumcision site to heal faster and more comfortably.

Choice C rationale:

• While ensuring a proper diaper fit is important for overall hygiene,it's not the most crucial aspect of post-circumcision care.A snug diaper can put unnecessary pressure on the healing penis,potentially causing irritation and discomfort.It's generally recommended to choose a diaper that fits comfortably without being too tight.

Choice D rationale:

• Using soap to wash the penis is not recommended during the healing process.Soap can be harsh and drying to the delicate tissues,potentially causing irritation and delaying healing.
• Warm water is sufficient for cleansing the area during diaper changes.