A 7-year-old girl is receiving IV antibiotics for osteomyelitis in the left femur.
After 72 hours of treatment, she continues to have fever, elevated WBC, and increased pain at the infection site. What is the nurse's priority action?

Choice A rationale

Acupressure involves applying pressure to specific points on the body, aiming to stimulate energy flow and relieve pain. While it can promote relaxation and analgesia by releasing endorphins, its direct effect on significantly reducing blood pressure and respiratory rate in acute anxiety may be less pronounced compared to methods emphasizing controlled breathing techniques.

Choice B rationale

Effleurage is a light, stroking massage, typically applied to the abdomen during contractions. This technique can distract from pain and promote relaxation by stimulating large nerve fibers, thereby reducing pain perception. However, its primary physiological impact is generally on pain modulation and comfort, rather than a direct, strong reduction in elevated blood pressure and respiratory rate.

Choice C rationale

The Bradley method, also known as "husband-coached childbirth," emphasizes natural childbirth, focusing on deep abdominal breathing, relaxation, and partner support. While it promotes a calm environment and can reduce overall stress, its specific techniques for immediate physiological regulation of acutely elevated blood pressure and erratic respirations may not be as direct as methods specifically teaching controlled breathing.

Choice D rationale

The Lamaze method focuses on controlled breathing and relaxation techniques during labor. These techniques, particularly patterned breathing, directly influence the autonomic nervous system by increasing vagal tone, which can lead to a decrease in heart rate and respiratory rate, thereby lowering blood pressure and promoting a sense of calm during periods of anxiety.

Choice E rationale

Yoga incorporates physical postures, breathing exercises (pranayama), and meditation. While highly effective for long-term stress reduction and improving cardiovascular health, its immediate application in a laboring client experiencing acute anxiety with elevated vital signs might be less practical for immediate physiological regulation compared to targeted breathing methods like Lamaze.

Choice A rationale

At 16 weeks of gestation, the uterine fundus has not yet reached the umbilicus. The umbilicus is typically reached around 20 weeks of gestation. Palpating the fundus at the umbilicus at 16 weeks would suggest a discrepancy in gestational age or a potential complication such as polyhydramnios or multiple gestation, warranting further investigation.

Choice B rationale

The uterine fundus is palpable at 16 weeks of gestation. By this stage, the uterus has grown significantly and ascended out of the pelvis, making it accessible to abdominal palpation. Failure to palpate the fundus at this stage could indicate an inaccurate gestational age, ectopic pregnancy, or other uterine abnormalities, requiring clinical correlation.

Choice C rationale

At 16 weeks of gestation, the uterine fundus is typically palpable approximately halfway between the symphysis pubis and the umbilicus. This anatomical landmark serves as a reliable indicator of gestational age during the second trimester. The fundus ascends by approximately 1 cm per week after 12 weeks of gestation, providing a consistent growth pattern.

Choice D rationale

At 16 weeks of gestation, the uterine fundus is well above the pubic bone. It typically becomes palpable just above the pubic bone around 12 to 14 weeks of gestation as it rises out of the pelvic cavity. Finding the fundus only just above the pubic bone at 16 weeks would suggest a lag in uterine growth or an inaccurate gestational age assessment.