A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin.

For which of the following findings should the nurse instruct the adolescent to monitor and report to the provider?

Correct answer: C

A) Start the first patch on the seventh day of the menstrual cycle: The patch is typically applied on the first day of the menstrual cycle or the first Sunday after the menstrual period begins, not on the seventh day. This helps ensure effective contraception from the start of use.

B) The contraceptive effect will continue for 6 months following discontinuation of the medication: The contraceptive effect of the patch does not last for 6 months after discontinuation. Once the patch is removed and not replaced, hormone levels drop, and fertility can return relatively quickly, typically within a few days to weeks.

C) Apply the patch to the lower abdomen: The patch should be applied to clean, dry, and intact skin on areas such as the lower abdomen, upper outer arm, buttock, or upper torso (excluding the breasts). This location allows for consistent hormone absorption.

D) Expect to have a headache during the first month: While some individuals may experience headaches as a side effect of hormonal contraceptives, this is not an expected or guaranteed outcome. Any persistent or severe headache should be reported to the healthcare provider, as it could indicate other concerns.

The first action the nurse should plan to perform is to check the client's ability to use the call light. This is essential to ensure that the client can easily communicate with the healthcare team if they need assistance or experience a fall risk situation. By confirming the client's ability to use the call light, the nurse can address any potential communication barriers and ensure that the client has a means to request help promptly.

Explanation for the other options:

b) Document the client's risk in the medical record: While documenting the client's risk in the medical record is important, it is not the first action to be taken. Ensuring the client's immediate safety and ability to request assistance is the priority.

c) Request a referral for physical therapy: Referring the client for physical therapy may be a necessary step to address their impaired mobility and reduce fall risk, but it is not the first action to be performed. Assessing their ability to use the call light takes precedence in order to address immediate safety concerns.

d) Place a gait belt in the client's room: Providing a gait belt is a measure to assist with mobility and falls prevention. However, it should not be the first action. Checking the client's ability to use the call light is more critical to ensure their immediate safety and ability to request help.