A nurse is teaching a client who is postpartum about caring for their newborn's umbilical cord. Which of the following instructions should the nurse include?

Answer: B. Turn on the faucets in the client's sink.

Rationale:

A. Tell the client to gently stroke their lower abdomen:
Stroking the abdomen may promote some sensory stimulation, but it is not a well-supported or commonly used intervention to stimulate voiding reflexes in clients having difficulty urinating on bed rest.

B. Turn on the faucets in the client's sink:
The sound of running water is a non-invasive, evidence-based method known to trigger the urge to urinate by stimulating the micturition reflex. This auditory cue can help relax pelvic muscles and facilitate urination, especially in clients struggling to void while in bed.

C. Pour cool water over the client's perineum:
Pouring cool water may not effectively stimulate urination and may cause discomfort. If water is used to promote voiding, it should be warm, not cool, to relax the perineal muscles and increase the likelihood of voiding.

D. Instruct the client to lean slightly backward:
Leaning backward can misalign the urethra and bladder, making voiding more difficult, especially for a female client in a supine or semi-recumbent position. A forward-leaning posture, if possible, is more anatomically favorable to aid urination.

Answer: B

Rationale:

A) Request insertion of a tracheostomy tube: The high-pressure alarm on a ventilator typically indicates increased resistance to airflow within the airway, which may be due to secretions, bronchospasm, or another obstruction. Requesting insertion of a tracheostomy tube is not the first action the nurse should take in response to a high-pressure alarm. Instead, the nurse should assess and manage potential causes of increased airway resistance before considering a change in airway management.

B) Suction the client's airway: Suctioning the client's airway is the priority action in response to a high-pressure alarm on the ventilator. Increased airway pressure may be due to secretions or a mucus plug, leading to airway obstruction. Suctioning helps clear the airway and restore effective ventilation.

C) Tighten the tubing connections: While loose tubing connections can contribute to air leaks and decreased ventilation efficiency, they are not the primary cause of a high-pressure alarm. Tightening tubing connections may be necessary but is not the initial action in response to a high-pressure alarm.

D) Look for a leak in the tube's cuff: Checking for a leak in the endotracheal tube cuff is essential to ensure an adequate seal and prevent aspiration. However, it is not the first action the nurse should take in response to a high-pressure alarm. The priority is to address potential airway obstruction by suctioning the client's airway to remove secretions or other obstructions.