A nurse in an acute pediatric unit is assessing a 5-year-old child following an asthma event.
The child's caregiver expects the child to use an inhaler without supervision. The nurse can apply which of the following interventions as protective factors for the child?

 

 

Rationale:

A. "My child will take the enzymes 2 hours before meals.": Pancreatic enzymes should be taken with meals or snacks, not before.

B. "My child will take the enzymes to improve her metabolism.": While pancreatic enzymes help with digestion, their purpose is not to improve metabolism.

C. "My child will take the enzymes to help digest the fat in foods.": This statement accurately reflects the purpose of pancreatic enzymes in cystic fibrosis. These enzymes are necessary because individuals with cystic fibrosis often have pancreatic insufficiency, leading to difficulty digesting fats and certain nutrients in food.

D. "My child will take the enzymes following meals.": Pancreatic enzymes should be taken with meals or snacks, not after.

Rationale:

A. Obtain a type and crossmatch: While obtaining a type and crossmatch may be necessary in the event of significant hemorrhage, the first action should be to address the potential cause of hypotension, which could be uterine atony.

B. Evaluate the firmness of the uterus: Postpartum hypotension is often caused by uterine atony, so the first action should be to assess the firmness of the uterus and massage it to stimulate contraction if necessary.

C. Administer oxytocin infusion: Oxytocin infusion may be necessary to help contract the uterus and control bleeding, but it should be implemented after assessing uterine firmness.

D. Initiate oxygen therapy by nonrebreather mask: While oxygen therapy may be needed if the client is hypotensive due to hemorrhage, assessing uterine firmness is the priority action to address the potential cause of hypotension.