A client who has uncontrollable urges to overeat gives a series of presentations in her workplace about nutrition guidelines for a healthy lifestyle. The nurse counseling this client should identify that the client is displaying which of the following defense mechanisms?

• Inspect the child’s oropharynx:After vomiting bright red blood, inspection can help confirm if bleeding is active in the throat. This assessment is key in identifying post-tonsillectomy hemorrhage.
• Obtaining a set of vital signs:Vital signs help evaluate the child’s hemodynamic stability, monitor for hypovolemic shock, and guide urgency for provider notification or surgical intervention.

Rationale for Incorrect Choices:

• Offer the child a red popsicle:Red-colored foods can mask signs of active bleeding. Also, offering oral intake during suspected hemorrhage is unsafe and may increase risk of aspiration.
• Place the child in a supine position:Supine positioning can increase aspiration risk if bleeding continues or worsens. The child should remain upright to protect the airway.
• Requesting a prescription for codeine:Codeine is not indicated in this situation and is contraindicated in children post-tonsillectomy due to risk of respiratory depression, especially during bleeding.
• Encouraging the child to cough and deep breathe:Coughing may dislodge clots and worsen bleeding. This action is inappropriate when bleeding is suspected in the oropharynx.

• Monitor fetal heart rate:After epidural placement, continuous fetal heart monitoring is essential due to the risk of uteroplacental hypoperfusion from maternal hypotension, which can alter fetal oxygenation and variability.
• Place client in left lateral position:This position improves uterine perfusion and prevents vena cava compression, which is especially critical post-epidural to stabilize maternal blood pressure and enhance fetal oxygenation.
• Administer ampicillin IV:The client tested positive for group B Streptococcus, which requires IV prophylactic antibiotics during labor to prevent neonatal sepsis, making this an essential intervention.
• Request a prescription for ephedrine:Ephedrine may be required to manage maternal hypotension, a common adverse effect of epidural anesthesia. Early signs like fetal heart rate changes warrant readiness to intervene.
• Decrease the IV flow rate:Reducing IV fluids post-epidural can worsen hypotension and compromise placental perfusion. Instead, increasing fluids is preferred to support circulating volume and maintain BP.