The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

Choice A reason: Monitoring indwelling urinary catheter and measure strict intake and output is not an action that the nurse should immediately take, as this is not relevant or urgent for a client who may have had a stroke. This is a distractor choice.

Choice B reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an action that the nurse should immediately take, as this is a preventive measure that does not address the acute problem of impaired cerebral perfusion. This is another distractor choice.

Choice C reason: Starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an action that the nurse should immediately take, as this can prepare the client for potential administration of tissue plasminogen activator (tPA), which can dissolve blood clots and restore blood flow to the brain if given within 4.5 hours of stroke onset. Therefore, this is the correct choice.

Choice D reason: Maintaining elevated positioning of the dependent joints on affected side is not an action that the nurse should immediately take, as this can worsen edema and impair circulation in the affected limbs. The recommended position is to keep them at or below heart level. This is another distractor choice.

Choice A reason: A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack. This client does not require immediate attention, as refusing to eat is a common behavior for clients with anorexia nervosa. The nurse should monitor the client's nutritional intake and weight, and provide education and support.

Choice B reason: An 18-year-old client with antisocial behavior who is being yelled at by other clients. This client does not require immediate attention, as being yelled at by other clients is not a life-threatening situation. The nurse should intervene to maintain a safe and therapeutic environment, and set limits on the client's disruptive behavior.

Choice C reason: A 16-year-old client diagnosed with major depression who refuses to participate in group. This client does not require immediate attention, as refusing to participate in group is a common symptom of depression. The nurse should encourage the client to join the group, and offer individual counseling and medication as needed.

Choice D reason: A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby. This client requires immediate attention, as pacing around the lobby may indicate that the client is experiencing mania, which can lead to impulsivity, aggression, or self-harm. The nurse should assess the client's mood, behavior, and thought process, and administer medication as prescribed.