A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid.
Which of the following actions should the nurse include in the plan of care?

Choice A rationale
While assessing the client’s kidney function is important in general, it is not the best way to evaluate medication adherence. Kidney function can affect the metabolism and excretion of medications, but it does not directly indicate whether the client is taking their medication as prescribed.
Choice B rationale

Correct answer. Checking the client’s serum medication level is the most direct and reliable way to evaluate medication adherence. If the client is taking the medication as prescribed, the serum medication level should be within the therapeutic range.
Choice C rationale
Determining the client’s apical pulse rate can provide information about the client’s overall cardiovascular status and can indicate certain drug effects or side effects, but it does not directly measure medication adherence.
Choice D rationale
Asking the client if they are taking the medication as prescribed can provide useful information, but it relies on self-report, which may not be reliable. Some clients might forget doses or not take the medication exactly as prescribed.

The correct answer is choice d. Assist the client to the bathroom.

Choice A rationale:

Inserting a urinary catheter is an invasive procedure and should be considered only after less invasive measures have been attempted and failed. It carries risks such as infection and trauma to the urethra.

Choice B rationale:

Pouring warm water over the client’s perineum can help stimulate urination, but it should be tried after assisting the client to the bathroom. It is a non-invasive method but not the first action to take.

Choice C rationale:

Offering a sitz bath can also help with urination by relaxing the perineal muscles, but it is not the first action to take. It is more appropriate if the client is unable to void after trying to use the bathroom.

Choice D rationale:

Assisting the client to the bathroom is the least invasive and most straightforward initial action. It allows the client to attempt to void naturally, which is preferable before trying other interventions.