A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?

Explanation

C. The client has developed difficulty ambulating

The information about the client's difficulty ambulating is relevant to the interprofessional team because it may require input and collaboration from various healthcare professionals to address and manage the client's mobility issues. This information helps the team understand the client's current condition and plan appropriate interventions.

The client having state-sponsored health insurance in (option A) is incorrect because it is not directly relevant to the interprofessional team meeting unless it specifically impacts the client's healthcare options, resources, or access to care. However, it may be important to know for insurance-related discussions or considerations, depending on the purpose of the team meeting.

The client's next dressing change being scheduled in 4 hours in (option B) is incorrect because it is important information for the nurse's own clinical responsibilities, but it may not be directly relevant to the broader interprofessional team meeting unless it has implications for the client's overall care plan or requires input from other team members.

The frequency of the client's vital sign checks being every 8 hours in (option D) is incorrect because it is important for the nurse's routine monitoring and care, but it may not be the primary focus of the interprofessional team meeting unless there are specific concerns or changes in the client's vital signs that need to be addressed collaboratively.

In summary, the nurse should include information about the client's difficulty ambulating during the interprofessional team meeting, as it helps inform the team's discussions, interventions, and plans regarding the client's mobility and potential impact on their overall care.

The correct answer is: a. Clean the stoma using an inward to outward circular motion.

Title: Choice A reason: Cleaning the stoma with an inward to outward circular motion is a recommended practice to prevent infection and ensure that any debris or secretions are cleared away from the tracheostomy site. This method helps to minimize the risk of introducing pathogens directly into the stoma and is considered a best practice in tracheostomy care.

Title: Choice B reason: Cleansing the inner cannula with isopropyl alcohol is not recommended because it can cause irritation to the tracheal mucosa. Instead, sterile saline is typically used for cleaning the inner cannula to avoid any potential damage to the tracheal tissues and to maintain a safe and comfortable environment for the patient.

Title: Choice C reason: Ensuring at least three finger widths of space under tracheostomy ties is not the standard practice. The recommended space is to allow one to two finger widths under the tracheostomy ties to ensure they are secure but not too tight, which could lead to skin breakdown or discomfort for the patient.

Title: Choice D reason: Preparing sterile supplies should be done before removing the inner cannula, not after. This is to ensure that all necessary supplies are ready to use immediately after the inner cannula is removed, minimizing the time the stoma is open and reducing the risk of infection.