A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

This is because the first priority for the nurse is to assess the cause of the vomiting and ensure that the NG tube is working properly. If the suction device is malfunctioning, it could lead to gastric distension, nausea and vomiting. The nurse should check the suction settings, tubing, canister and connections for any problems.

Choice A is wrong because replacing the NG tube is not the first action to take.

The nurse should first rule out other causes of vomiting before attempting to reinsert the tube, which could be uncomfortable and risky for the client.

Choice B is wrong because providing oral hygiene care is not the most urgent action to take.

While oral hygiene care is important for comfort and infection prevention, it does not address the underlying cause of vomiting or prevent further complications.

Choice C is wrong because administering an antiemetic medication is not the most appropriate action to take.

The nurse should first identify the cause of vomiting and correct it if possible.

Giving an antiemetic medication without resolving the problem could mask symptoms and delay treatment.

This action demonstrates the nurse’s role as an advocate and a resource person for the client, who might be eligible for financial assistance and health care coverage during her pregnancy and the postpartum period. Medicaid is a federal and state program that provides health insurance for low-income individuals and families.
Choice A is wrong because contacting the adolescent’s parent for assistance might violate the client’s confidentiality and autonomy, especially if the parent is not aware of or supportive of the pregnancy. The nurse should respect the client’s right to privacy and self-determination unless there is a risk of harm to the client or the fetus.
Choice C is wrong because referring the adolescent to a local mental health clinic might imply that the client has a mental disorder or needs psychological counseling, which could be stigmatizing and discouraging.
The nurse should assess the client’s emotional state and coping skills, and provide supportive and nonjudgmental care. The nurse can also offer referrals to other community resources, such as prenatal education, parenting classes, or social services, that might benefit the client.
Choice D is wrong because advising the adolescent to place the newborn for adoption might interfere with the client’s decision-making process and personal values.
The nurse should not impose his or her own opinions or beliefs on the client but rather explore the client’s feelings and preferences about her pregnancy options. The nurse should provide factual information and education about adoption, abortion, or parenting, and help the client weigh the benefits and risks of each option.