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Adjusting the intravenous fluid infusion rate is not the immediate priority after an amniotomy. The primary concern is the potential for umbilical cord prolapse due to the gush of amniotic fluid, which can compromise fetal oxygenation. The fluid rate can be addressed after ensuring fetal well-being.

Providing a clean gown and linens is important for client comfort and hygiene but is not a priority over assessing fetal status. A change in linens can be done after the immediate safety of the fetus is confirmed, as a compromised fetal heart rate requires immediate intervention.

Assisting the client with perineal hygiene is an important comfort measure and infection prevention strategy, but it is not the most critical and immediate action. The potential for a sudden, life-threatening change in fetal status due to cord prolapse takes precedence over hygiene.

Chronic anemia is not a primary complication of Kawasaki syndrome. The disease process is a vasculitis that primarily affects medium-sized arteries, leading to inflammation and damage. The acute inflammatory state can cause temporary anemia, but it is not a chronic sequela prevented by IVIG and aspirin.

Cardiac arrhythmias are not the primary long-term complication targeted by IVIG and aspirin therapy. The main concern is the weakening of the coronary artery walls due to inflammation, which can lead to the formation of aneurysms. Arrhythmias can occur but are not the main focus of this specific treatment.

Acute respiratory distress is not a typical complication of Kawasaki syndrome. The syndrome is a systemic vasculitis, not a primary pulmonary disease. Respiratory symptoms like cough or runny nose are part of the initial presentation but are not the serious, life-threatening complication that IVIG and aspirin are given to prevent.Choice D rationale
Coronary artery aneurysms are the most serious long-term complication of Kawasaki syndrome. The intense inflammation of the blood vessel walls, known as vasculitis, can lead to weakening and bulging of the coronary arteries. High-dose aspirin and IVIG reduce this systemic inflammation, thereby preventing the formation of these aneurysms.
 

A fetal heart rate (FHR) of 110 beats per minute with moderate variability and accelerations is within the normal range (110-160 bpm). Moderate variability indicates a healthy, well-oxygenated fetus, and accelerations are reassuring signs. This client is stable and does not require immediate intervention.

A client with an epidural who is 7 cm dilated is stable. The nurse should continue to monitor the client's progress and vital signs, but there is no indication of immediate distress. The epidural can cause a slight decrease in blood pressure, which would require monitoring but not an urgent response.

A blood pressure of 110/82 mmHg, heart rate of 80 beats per minute, and oxygen saturation of 98% are all within normal ranges. This client is stable and does not have any signs of distress. The nurse should continue to monitor the client but does not need to see them first.

Applying butter to a burn is a harmful practice. Butter holds heat against the skin, which can worsen the tissue damage. Additionally, it can trap bacteria, increasing the risk of infection. The oil in the butter can also interfere with proper medical evaluation and treatment of the burn.

Wrapping the child in a blanket and rushing him to the hospital is not the first action. The immediate priority is to stop the burning process. The heat from the scalding tea continues to damage tissue. A blanket can also retain heat and worsen the burn. The priority is to cool the skin first.

Removing the shirt is a good idea to prevent the trapped heat from worsening the burn, but applying burn ointment is not the first action. Immediate cooling with water is the priority. Burn ointments can trap heat and complicate medical assessment, as they must be removed before the burn can be properly evaluated.

Placing one hand on the fundus while the other is on the perineum is an incorrect technique. This method fails to provide counterpressure to the lower uterine segment, which is essential to prevent uterine inversion during fundal massage. The uterus must be stabilized to ensure safe and effective palpation and massage.

Palpating the fundus with only fingertip pressure is an incorrect technique. This light pressure is insufficient to accurately assess uterine tone and position. Effective palpation requires firm but gentle pressure to compress the uterine wall and determine its height, tone, and midline placement.

Resting both hands on the fundus is an incorrect technique. This method fails to provide adequate counterpressure to the lower uterine segment. Without this stabilization, there is an increased risk of uterine inversion when massaging or assessing the fundus, a potentially life-threatening complication.

Measuring blood pressure hourly is an important part of monitoring a postpartum client, but it is not the priority. While vital signs are crucial, the immediate physiological threat is ongoing hemorrhage from uterine atony, which must be addressed directly to prevent shock.

Preparing to administer blood products may become necessary if the client experiences significant blood loss, but it is not the initial priority. The first intervention is to stop or reduce the bleeding by promoting uterine contraction, which will minimize the need for subsequent blood transfusions.

Administering intravenous fluids is a supportive measure to maintain circulatory volume, but it does not address the underlying cause of the hemorrhage. The priority is to stimulate uterine contractions to compress the myometrial arteries and prevent further blood loss.

Docusate sodium is a stool softener used to treat constipation and is not indicated for an acute ingestion of ferrous sulfate. Administering this medication would not address the toxic effects of iron overdose, which can cause severe gastrointestinal and metabolic acidosis.

Giving a child orange juice is not an appropriate action. While vitamin C in orange juice can enhance iron absorption, this is dangerous in an overdose situation. The priority is to prevent further systemic absorption of the toxic iron.

Inducing vomiting is no longer a recommended intervention for most ingestions, including iron, due to the risk of aspiration and the limited effectiveness in removing all the ingested substance. The corrosive nature of iron can also cause esophageal damage upon emesis.

A localized area of breast tenderness is a potential sign of mastitis, which, while requiring attention, is not an immediate life-threatening condition. The client can be seen after more acute priorities, as mastitis typically develops over days.

A pain score of 3/10 in a 4-hour post-op client is an expected finding and can be addressed after more critical clients. This level of pain is not indicative of an acute, unstable physiological state that requires immediate intervention.

Moderate, dark red lochia is a normal finding 4 hours postpartum. The lochia is a mixture of blood, tissue, and mucus, and its color and amount are expected to change over time without indicating an immediate danger to the client.