A woman is in her seventh month of pregnancy.
She has been reporting nasal congestion and occasional epistaxis.
The nurse suspects that.

Choice A rationale:

Facilitate maternal-newborn interaction. Facilitating maternal-newborn interaction is an important aspect of breastfeeding, but it is not the primary purpose of encouraging breastfeeding immediately after an emergency birth. The primary purpose is to initiate the lactation cycle, allowing the newborn to receive essential colostrum, the first milk rich in antibodies and nutrients, which aids in the development of the newborn's immune system.

Choice B rationale:

Stimulate the uterus to contract. While breastfeeding can stimulate uterine contractions due to oxytocin release, the primary purpose of encouraging breastfeeding in this context is not to contract the uterus but to initiate the lactation cycle for the newborn's benefit.

Choice C rationale:

Prevent neonatal hypoglycemia. Breastfeeding can help prevent neonatal hypoglycemia by providing the newborn with a constant supply of nutrients, but the primary purpose immediately after an emergency birth is to initiate the lactation cycle and provide colostrum, not solely to prevent hypoglycemia.

Choice D rationale:

Initiate the lactation cycle. Initiating the lactation cycle is the correct answer because breastfeeding immediately after birth helps the woman's body start producing milk and provides the newborn with colostrum, essential for their health and development. Colostrum is rich in antibodies and nutrients, offering vital protection and nourishment to the newborn.

The correct answer is choice c. Verbalizing the importance of monitoring for medication side effects.

Choice A rationale:

Relieving constipation is not typically a priority for patients with Graves’ disease, as constipation is not a common symptom of this condition.

Choice B rationale:

While involving adolescents in their care decisions is important, allowing them to decide whether or not to take medication is not appropriate. Adherence to medication is crucial for managing Graves’ disease.

Choice C rationale:

Verbalizing the importance of monitoring for medication side effects is essential. Graves’ disease treatment often involves medications that can have significant side effects, and monitoring these is critical for effective management and patient safety.

Choice D rationale:

Developing alternative educational goals is not directly related to the immediate management of Graves’ disease. While educational support is important, it is not the primary nursing goal in this context.