A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?

Explanation

C. Skin rash with fever

Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening hypersensitivity reaction that can occur as a rare side effect of certain medications, including allopurinol.

Monitoring and early recognition of SJS symptoms are crucial for prompt medical.

Skin rash with fever is a hallmark manifestation of Stevens-Johnson syndrome. It often starts with flu-like symptoms such as fever and malaise, followed by the appearance of a widespread, painful, and rapidly progressing rash. The rash typically involves the mucous membranes, including the mouth, nose, and eyes, and can be accompanied by blisters or sores. Prompt reporting of these symptoms is critical for early diagnosis and intervention.

Tinnitus with ear pain in (option A) is incorrect because it is not typically associated with Stevens- Johnson syndrome. It may indicate another condition or side effect unrelated to SJS.

Hyperreflexia, which refers to abnormally increased reflexes, in (option B) is incorrect because it is not a characteristic manifestation of Stevens-Johnson syndrome. It may indicate a neurological condition or reaction to another medication, but it is not specific to SJS.

Diplopia, or double vision, in option (D) is incorrect because it is not commonly associated with Stevens- Johnson syndrome. It may be caused by other ocular or neurological conditions.

In summary, the nurse should instruct the client taking allopurinol to monitor and report the manifestation of a skin rash with fever. This is important because it may indicate the development of Stevens-Johnson syndrome, a severe and potentially life-threatening reaction to the medication. Early recognition and medical intervention are crucial to minimize complications and ensure appropriate treatment.

When a central venous catheter (CVC) is inserted, it is essential to confirm proper catheter placement to ensure safe and effective administration of TPN and other medications. A chest x-ray is the gold standard method to verify the correct positioning of the CVC tip. It helps determine if the catheter is appropriately positioned in the superior vena cava or another desired location, which minimizes the risk of complications such as pneumothorax or improper medication delivery.

The other options listed are not appropriate actions for the nurse to take in this situation:

1. Verifying the amount of TPN solution the client is receiving every 4 hours is a task related to ongoing monitoring of TPN administration, but it is not directly related to the preparation of the client for CVC insertion.
2. Using clean technique when changing the catheter dressing is not appropriate for CVC insertion. Sterile technique is required during the insertion of a CVC to minimize the risk of infection.
3. Placing the client in Sims' position is not the appropriate position for CVC insertion. The client is typically placed in a supine or Trendelenburg position during the procedure to facilitate access to the central venous system.