A nurse is caring for a patient who is in labor and has an epidural anesthesia block. The patient’s blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min.
Which of the following is the priority nursing action?

Choice A rationale

Lubricating the suction catheter tip with sterile saline is not recommended because it can introduce bacteria into the tracheostomy tube and cause infection.

Choice B rationale

Hyperventilating the patient on 100% oxygen prior to suctioning is not necessary and can cause complications such as oxygen toxicity.

Choice C rationale

Performing chest physiotherapy prior to suctioning is not typically done during tracheostomy care. Chest physiotherapy is a separate procedure that involves physical techniques to remove mucus from the respiratory tract.

Choice D rationale

Suctioning two to three times with a 60-second pause between passes is the correct action. This helps to remove secretions effectively without causing hypoxia.

Choice A rationale

The hospital pharmacist is the most appropriate resource for a nurse to consult for information on medication compatibility. Pharmacists have specialized knowledge and access to resources that provide information on drug interactions, including those between ampicillin and gentamicin sulfate. They can provide accurate and up-to-date information on whether these two medications can be safely administered together.

Choice B rationale

While the health care provider prescribes the medication, they may not have the most current or detailed information on drug compatibility. It is the pharmacist’s role to have this specialized knowledge.

Choice C rationale

Medication sales representatives are primarily focused on promoting their company’s products. They may not have comprehensive knowledge of drug interactions, especially between drugs from different companies.

Choice D rationale

The nurse manager oversees the nursing staff and coordinates care, but they may not have specific knowledge about all drug interactions. The hospital pharmacist is the most appropriate resource for this information.