A nurse is caring for a client who is requesting to go to the bathroom immediately after a vaginal birth. Which of the following actions should the nurse take?

Choice A rationale:
A Speech Therapist is crucial in this case. The patient presented with garbled speech, which indicates a possible speech impairment. A speech therapist can evaluate the patient’s speech and language skills and provide therapy to improve any deficits, which can significantly enhance the patient’s quality of life.
Choice B rationale:
A Case Manager is essential in coordinating the patient’s care. They ensure that the patient’s healthcare needs are met and that the patient is receiving appropriate treatments. They also coordinate with various healthcare professionals and may assist with insurance issues or discharge planning.
Choice C rationale:
A Physical Therapist can help the patient regain physical strength and mobility that might have been affected by the stroke. They can provide exercises and treatments to improve balance, coordination, and muscle strength, which can help the patient regain independence in their daily activities.
Choice D rationale:
A Pharmacy Technician is not typically involved in direct patient care or recovery. Their role is more focused on assisting pharmacists with dispensing medication and other administrative tasks in a pharmacy setting.
Choice E rationale:
The Chief Nursing Officer (CNO) is a high-level executive role that oversees nursing staff across an entire healthcare organization. While they play a crucial role in ensuring quality nursing care, they would not be directly involved in individual patient recovery.
Choice F rationale:
A Respiratory Therapist could be helpful if the patient had respiratory issues or complications related to the stroke, but given the information provided, it does not appear that respiratory therapy is needed in this case.
Choice G rationale:
A Medical Assistant typically performs administrative and clinical tasks in healthcare settings but does not specialize in rehabilitation or recovery care for stroke patients.
Choice H rationale:
An Occupational Therapist is vital for stroke recovery. They can help the patient regain skills needed for daily living activities that might have been affected by the stroke, such as eating, dressing, and bathing. They can also provide strategies to compensate for any lasting deficits from the stroke. In summary, for a comprehensive recovery plan for this patient who has had a stroke, an interdisciplinary team involving a Speech Therapist (A), Case Manager (B), Physical Therapist ©, and Occupational Therapist (H) would be most beneficial.

Choice A rationale:

Monitoring ETT markings between 22 and 26 cm at the teeth line is essential to ensure proper placement of the endotracheal tube (ETT). This helps confirm that the ETT is positioned correctly in the trachea.

Choice B rationale:

Checking for capillary refill is not a reliable method for verifying the placement of an ETT. It is more indicative of peripheral circulation and not related to airway management.

Choice C rationale:

Obtaining a portable chest x-ray is a crucial step to verify the exact placement of the ETT within the trachea and to rule out potential complications such as pneumothorax.

Choice D rationale:

Assessing for symmetrical chest movement is important because unequal chest rise and fall could indicate an issue with ETT placement or lung function.

Choice E rationale:

Auscultating for bilateral breath sounds is another method to confirm that the ETT is correctly positioned in the trachea and that both lungs are being ventilated adequately.