When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

Choice A reason: This is a correct answer because obtaining postoperative vital signs for a client one day following unilateral knee arthroplasty is a nursing action that can be assigned to the PN. Vital signs are measurements of the body's basic functions, such as temperature, pulse, blood pressure, and respiration. Vital signs should be monitored regularly after surgery to detect any signs of infection, bleeding, shock, or pain. The PN has the knowledge and skill to measure and record vital signs and report any abnormal findings to the nurse.

Choice B reason: This is a correct answer because performing daily surgical dressing change for a client who had an abdominal hysterectomy is a nursing action that can be assigned to the PN. Surgical dressing is a material that covers and protects a wound from infection, bleeding, or contamination. Surgical dressing should be changed daily or as needed to keep the wound clean and dry and promote healing. The PN has the knowledge and skill to perform surgical dressing change using sterile technique and appropriate equipment and report any signs of wound infection or dehiscence to the nurse.

Choice C reason: Initiating patient controlled analgesia (PCA) pumps for two clients immediately postoperatively is not a nursing action that can be assigned to the PN. PCA pump is a device that allows the client to self-administer pain medication through an IV line by pressing a button. PCA pump should be initiated by the nurse after verifying the prescription, setting the parameters, educating the client, and ensuring safety and effectiveness. The PN does not have the authority or competency to initiate PCA pump or adjust its settings.

Choice D reason: Starting the second blood transfusion for a client twelve hours following a below knee amputation is not a nursing action that can be assigned to the PN. Blood transfusion is a procedure that delivers donated blood or blood products into the client's bloodstream through an IV line. Blood transfusion should be started by the nurse after verifying the prescription, checking the blood type and compatibility, obtaining informed consent, and monitoring for any adverse reactions. The PN does not have the authority or competency to start blood transfusion or manage its complications.

Choice E reason: This is a correct answer because monitoring a dose of warfarin per protocol for a client with type 2 diabetes mellitus (DM) is a nursing action that can be assigned to the PN. Warfarin is an anticoagulant medication that prevents blood clots by inhibiting vitamin K dependent clotting factors. Warfarin should be monitored per protocol by checking the international normalized ratio (INR), which measures how long it takes for blood to clot. The PN has the knowledge and skill to monitor warfarin per protocol by obtaining blood samples, performing point-of-care testing, and reporting results to the nurse.

Choice A reason: Obtain a capillary glucose level. This is the first action that the nurse should do, as it can diagnose hypoglycemia, which is a low blood sugar level that can cause jitteriness and tachypnea in newborns. Hypoglycemia can be caused by maternal diabetes, prematurity, infection, or delayed feeding. The nurse should check the glucose level using a heel stick and a glucometer.

Choice B reason: Feed 30 mL of 10% dextrose in water. This is not the first action that the nurse should do, as it may not be appropriate for all newborns with jitteriness and tachypnea. Feeding 10% dextrose in water can raise the blood sugar level, but it may also cause rebound hypoglycemia or fluid overload. The nurse should feed only after confirming hypoglycemia and obtaining a healthcare provider's order.

Choice C reason: Wrap tightly in a blanket. This is not the first action that the nurse should do, as it may not address the underlying cause of jitteriness and tachypnea in newborns. Wrapping tightly in a blanket can prevent heat loss and conserve energy, but it may also impair breathing or circulation. The nurse should wrap only after ruling out other causes of jitteriness and tachypnea.

Choice D reason: Encourage the mother to breastfeed. This is not the first action that the nurse should do, as it may not be feasible or effective for all newborns with jitteriness and tachypnea. Breastfeeding can provide nutrition and bonding for newborns, but it may also be difficult or contraindicated for some newborns with respiratory distress or infection. The nurse should encourage breastfeeding only after assessing and stabilizing the newborn's condition.