A nurse is caring for a client who is 1 hr postpartum and unable to urinate.
Which of the following actions should the nurse take?

Choice A rationale:

Including any adverse effects of the medications the client might develop is important but does not cover the entire scope of medication reconciliation. It is essential to compare new prescriptions with the list of current medications to prevent drug interactions, duplications, or omissions.

Choice B rationale:

Comparing new prescriptions with the list of medications the client reports is the correct approach to medication reconciliation. This helps identify discrepancies, ensuring that the client's current medications are accurately documented and preventing medication errors.

Choice C rationale:

Excluding nutritional supplements from the list of medications the client reports is incorrect. Nutritional supplements, herbal remedies, and over-the-counter medications are essential components of the medication list. These items can interact with prescribed medications and affect the client's overall health.

Choice D rationale:

Encouraging the client to make his own list after he returns home is not recommended. Patients might not have complete knowledge of the medications they are taking, including dosages and frequencies. Relying solely on the patient-generated list can lead to inaccuracies and potential harm.

Question 1: The correct answer is Choice A - Stabilize the tube by taping it to the infant’s cheek.

Choice A Rationale: Stabilizing the nasogastric tube by taping it to the infant's cheek is crucial to prevent displacement, which could lead to complications such as misplacement into the respiratory tract or discomfort for the infant. Proper securing ensures the tube remains in the intended position, facilitating the safe and effective delivery of nutrients. This action aligns with standard nursing practices to promote patient safety and comfort during enteral feedings.

Choice B Rationale: Option B suggests positioning the infant in a supine position during feedings, which is incorrect. Placing the infant in a supine position increases the risk of aspiration due to the potential for reflux. Instead, the infant should be positioned upright or semi-upright with the head elevated to minimize the risk of regurgitation and aspiration.

Choice C Rationale: Aspiration of residual fluid from the infant's stomach and discarding it (Option C) is not recommended practice. Aspirated gastric contents should be measured and assessed for volume and color to evaluate gastrointestinal function and potential complications. Discarding the aspirate without evaluation could lead to the oversight of important clinical indicators or abnormalities in the infant's condition.

Choice D Rationale: Microwaving the infant's formula to a temperature of 41°C (105.8°F) (Option D) is an incorrect practice. Heating formula in a microwave can result in uneven temperature distribution, creating hot spots that may cause burns to the infant's delicate oral mucosa or esophagus. The preferred method for warming formula is to use a water bath or bottle warmer to achieve a consistent temperature close to body temperature (around 37°C or 98.6°F).