A nurse is assessing for pain for a client following a cesarean birth 24 hr ago. Which of the following questions should the nurse ask to determine if a PRN pain medication is indicated?

Explanation

Choice A Reason:

Reporting the guardian's refusal of the medication to social services is incorrect. Refusing a medication for a newborn, especially one that is standard practice like erythromycin ophthalmic ointment, does not automatically warrant reporting to social services. Reporting to social services should only occur in cases where there are concerns for the safety or well-being of the newborn.

Choice B Reason:

Documenting the guardian's refusal of the medication. Is correct. When a guardian refuses a prescribed medication for a newborn, the nurse's immediate responsibility is to document this refusal accurately in the medical record. Documentation ensures that the refusal is well-documented for future reference and legal purposes.

Choice C Reason:

Informing the guardian that the medication can be given after discharge is incorrect. While it's important to educate the guardian about the purpose and benefits of the medication, informing them that it can be given after discharge may not address the immediate need for prophylaxis against ophthalmia neonatorum, which is the infection erythromycin ophthalmic ointment is intended to prevent.

Choice D Reason:

Notifying the facility's ethics committee about the guardian's medication refusal is incorrect. In most cases, notifying the ethics committee would be an overreaction to a guardian's refusal of a standard prophylactic medication. Ethics committees are typically reserved for complex ethical dilemmas that require deliberation and guidance beyond standard practice.

Explanation

Choice A Reason:

"You should have your provider refit you for a new diaphragm. “This is appropriate. After childbirth, a woman's body can undergo changes, including changes in vaginal tone and size. Therefore, it's essential for women who want to continue using a diaphragm for contraception postpartum to have their provider refit them for a new diaphragm. This ensures that the diaphragm fits properly and provides effective contraception.

Choice B Reason:

"You should keep the diaphragm in place for at least 4 hours after intercourse." While it's important to leave the diaphragm in place for a certain period after intercourse (typically at least 6-8 hours), the exact duration may vary depending on the type of diaphragm and the specific instructions provided by the healthcare provider or manufacturer. However, the recommended duration is typically longer than 4 hours.

Choice C Reason:

"You should use an oil-based vaginal lubricant when inserting your diaphragm." It is not recommended to use oil-based vaginal lubricants with diaphragms, as they can weaken the latex and increase the risk of the diaphragm tearing or becoming less effective as a contraceptive method. Water-based lubricants are typically recommended for use with diaphragms.

Choice D Reason:

"You should store your diaphragm in sterile water after each use." Storing the diaphragm in sterile water after each use is unnecessary and may not be practical. Instead, diaphragms should be cleaned with mild soap and water, dried, and stored in their case in a cool, dry place when not in use. Storing the diaphragm in sterile water is not a standard recommendation.