The nurse is continuing to care for the client.

Exhibits

The nurse is initiating the client's plan of care.

Which of the following interventions should the nurse plan to implement? Select all that apply.

The correct answer is D.

Choice A reason: “A. Using this machine increases my risk of overdose.” This statement is incorrect because PCA pumps are designed with safety mechanisms to prevent overdose. The pump is programmed to deliver a specific dose of medication at set intervals, and it will not dispense more medication than what is prescribed by the healthcare provider.

Choice B reason: “B. I can get pain medication any time as long as I press the button.” While it is true that the patient can self-administer medication, PCA pumps have a lockout interval that prevents the machine from delivering another dose until a certain amount of time has passed, ensuring that the patient cannot receive medication too frequently.

Choice C reason: “C. My partner can press my pain medication button for me if I am sleeping.” This statement is incorrect. Only the patient should press the button on the PCA pump to ensure that the medication is administered safely and according to the patient’s current level of pain. Allowing someone else to press the button could lead to unsafe dosing.

Choice D reason: “D. I will receive a limited amount of pain medication when I press the button.” This is the correct statement. The PCA pump allows the patient to administer a controlled amount of pain medication within safe limits set by the healthcare provider. The pump is programmed to deliver a specific dose of medication, and there is a limit to the number of doses that can be administered per hour.

Choice A rationale:

Taking ibuprofen during pregnancy is generally not recommended, especially in high doses or for an extended period, as it can increase the risk of complications, including heart defects in the baby. Therefore, advising the client to take 600 milligrams of ibuprofen every 8 hours is not appropriate and potentially harmful during pregnancy.

Choice B rationale:

Having a cesarean birth (C-section) is recommended if there are visible lesions of genital herpes during labor and delivery. This precautionary measure helps prevent the transmission of the herpes simplex virus (HSV) from the mother to the baby, reducing the risk of neonatal herpes infection, which can be severe or even life-threatening.

Choice C rationale:

Testing the baby's cord blood for HSV is not a standard practice. Instead, if there are visible lesions or symptoms of herpes during labor, a C-section is often performed to minimize the risk of transmission. Testing the baby after birth may be done if there are concerns about potential exposure.

Choice D rationale:

Applying a cortisone cream to the lesions is not recommended without medical supervision during pregnancy. Topical corticosteroids, such as cortisone creams, can be absorbed through the skin and may have adverse effects on both the mother and the baby. It is essential to consult a healthcare provider before using any medications or creams during pregnancy to ensure safety for both the mother and the baby.