The nurse is assisting in the administration of IV vancomycin to a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings indicate an allergic reaction to the medication?

Rationale:

A. A client who has a firm fundus following a vaginal birth and reports continuous perineal pain of 8 on a scale of 0 to 10: Although the fundus is firm, severe continuous perineal pain may indicate complications such as hematoma or infection, requiring immediate assessment and intervention to prevent worsening condition.

B. A client who is 30 hr postpartum and reports feeling tearful and overwhelmed: Postpartum emotional lability is common in this timeframe and generally not an immediate safety concern. The nurse should provide support but this client’s condition is not urgent.

C. A client who is 12 hr postpartum and reports having to urinate frequently: Frequent urination postpartum may be due to diuresis or normal bladder function return and is not typically urgent unless accompanied by other signs of infection or retention.

D. A client who had a cesarean birth yesterday and reports burning incision pain of 5 on a scale of 0 to 10: Moderate incision pain is expected after surgery and can be managed with analgesics; it does not require immediate intervention compared to potential perineal complications.

Rationale:

A. The weights apply a pulling force continuously: Buck’s traction is a form of skin traction used to immobilize fractures and reduce muscle spasms. The weights must hang freely and provide a constant pulling force to maintain alignment and promote healing.

B. The boot allows active leg movement: In Buck’s traction, the affected leg should be immobilized. Active movement would interfere with the consistent traction force and compromise the effectiveness of the treatment.

C. The footplate rests against the foot of the bed: The client’s foot should not press against the bedframe or footplate, as this can counteract the traction force and cause improper alignment. There should be adequate space for traction to be effective.

D. The weights are just touching the floor: Weights should hang freely and never touch the floor. If they rest on the floor, the traction force is lost, defeating the purpose of the setup and potentially leading to complications.