A nurse is caring for a male client who has a spinal cord injury.
Which of the following techniques should the nurse use when providing perineal care?

 

The correct answer is choiceC. “Have your child drink a small glass of water after swallowing the medication.”

Choice A rationale:

Adding digoxin to a half-cup of juice is not recommended because it can affect the absorption of the medication.It is best to give digoxin on an empty stomach or with a small amount of food if necessary.

Choice B rationale:

Limiting potassium intake is incorrect.In fact, maintaining adequate potassium levels is important because low potassium levels can increase the risk of digoxin toxicity.

Choice C rationale:

Having the child drink a small glass of water after taking the medication helps ensure that the medication is swallowed completely and reduces the risk of esophageal irritation.

Choice D rationale:

Repeating the dose if the child vomits within 1 hour is not recommended. If a dose is vomited, it should not be repeated to avoid the risk of overdose.The next dose should be given at the regular scheduled time.

The correct answer is choice A, B, D, and F.

Choice A rationale:

The presence of protein in the urine (proteinuria) is a sign of potential prenatal complication. Normally, urine should be protein negative. Proteinuria can be a sign of preeclampsia, a serious condition that includes high blood pressure and swelling, and can lead to preterm birth or other serious complications if not managed.

Choice B rationale:

The client’s blood pressure is 162/112 mm Hg, which is significantly higher than the normal range (less than 120/80 mm Hg). High blood pressure during pregnancy could indicate preeclampsia or other complications.

Choice C rationale:

The client’s respiratory rate is 16/min, which falls within the normal range (12-20 breaths per minute). Therefore, it does not indicate a potential prenatal complication.

Choice D rationale:

The client’s report of a severe headache unrelieved by acetaminophen is concerning. This could be a symptom of preeclampsia or other serious conditions and should be investigated further.

Choice E rationale:

The client’s gravida/parity (G3 P2 with one preterm birth) does not directly indicate a potential prenatal complication. However, a history of preterm birth could put the client at higher risk for another preterm birth.

Choice F rationale:

The client’s report of decreased fetal movement is concerning. Decreased fetal movement can be a sign of fetal distress or other complications and should be investigated further.

Choice G rationale:

The client’s urine does not contain ketones, which would indicate that the body is using fat for energy instead of glucose. This could occur in cases of poor nutrition or gestational diabetes. Since the urine is ketone negative, this does not indicate a potential prenatal complication.