A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion.
Which of the following actions should the nurse plan to take?

Choice A rationale:

Taking temperature within 30 minutes after the first morning void is specific to ovulation prediction kits, not the basal body temperature method.

Choice B rationale:

Taking temperature 1 hour after getting out of bed is not accurate for tracking basal body temperature fluctuations related to the menstrual cycle.

Choice C rationale:

Taking temperature every night before going to bed does not provide consistent basal body temperature readings, as the body temperature needs to be taken at the same time every morning to detect subtle changes related to the menstrual cycle.

Choice D rationale:

This is the correct answer. To use the basal body temperature method effectively, the client should take their temperature immediately after waking and before getting out of bed every morning. This helps in detecting the slight rise in basal body temperature that occurs after ovulation, indicating the fertile period.

A.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.

B.Applying lubricant to the site is not necessary or recommended. The gastrostomy tube should be kept clean and dry. If any secretions or debris are present, they should be gently cleaned with mild soap and water, followed by thorough rinsing and drying.

C.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.

D.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.