A nurse is caring for a 2-year-old child who has Clostridium difficile.
Which of the following actions should the nurse take?

Instruct the parents to avoid bringing fresh flowers into the room.

Initiate contact precautions.

Place the child in a room that has a HEPA filtration system.

Use an N95 respirator.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Instructing parents to avoid bringing fresh flowers into the room is not the primary intervention for a child with Clostridium difficile. While it is essential to maintain a clean environment, the most critical action is to implement proper infection control measures.

Choice B rationale:

This is the correct answer. Initiating contact precautions is crucial when caring for a child with Clostridium difficile. This includes using gloves and gowns to prevent the spread of the bacteria to others.

Choice C rationale:

Using a HEPA filtration system in the room is not the first-line intervention for managing Clostridium difficile. While it can help maintain air quality, it does not directly address the transmission of the bacteria.

Choice D rationale:

Using an N95 respirator is not the primary action in caring for a child with Clostridium difficile. Contact precautions, such as gloves and gowns, are more critical to prevent the spread of infection.

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Correct Answer is ["B","D","E","F"]

Explanation

Choice A rationale:

Performing intermittent external electronic fetal monitoring is not the best choice in this situation. The client’s condition, which includes severe abdominal pain, vaginal bleeding, rigid and tender abdomen, and late decelerations in the fetal heart rate, suggests a possible placental abruption. In such a case, continuous fetal monitoring is required to closely monitor the fetal heart rate and contractions.

Choice B rationale:

Monitoring vital signs at least every 15 min is necessary. The client’s blood pressure has dropped from 110/68 mm Hg to 95/59 mm Hg within 15 minutes. This could indicate hypovolemia due to blood loss. Regular monitoring can help detect changes early and initiate appropriate interventions.

Choice C rationale:

Placing the client in a supine position is not recommended. This position can exacerbate supine hypotensive syndrome, which occurs when the gravid uterus compresses the inferior vena cava, reducing venous return and cardiac output. A side-lying position would be more appropriate.

Choice D rationale:

Obtaining a type and crossmatch is crucial. The client’s symptoms suggest a possible placental abruption, which can lead to significant blood loss. Having blood available for transfusion can be lifesaving.

Choice E rationale:

Measuring blood loss by weighing pads can provide an objective assessment of blood loss. This can help guide treatment decisions, including the need for blood transfusion.

Choice F rationale:

Inserting a large-bore IV catheter is necessary in this situation. It allows for rapid fluid and blood replacement if needed. Given the client’s symptoms and the potential for significant blood loss with placental abruption, this intervention is appropriate.

A. 8 oz fruit yogurt. B. 8 oz raw spinach. C. 8 oz chopped hard-boiled egg. D. 8 oz brown rice.

Correct Answer is C

Explanation

Choice A rationale:

8 oz of fruit yogurt contains protein, but it is not as protein-rich as the other options. Yogurt is more commonly consumed for its probiotic benefits and calcium content.

Choice B rationale:

8 oz of raw spinach contains some protein but is not a high source of protein compared to the other options. Spinach is often chosen for its high iron and fiber content.

Choice C rationale:

8 oz of chopped hard-boiled egg is a significant source of protein. Eggs are well-known for their high-quality protein content.

Choice D rationale:

8 oz of brown rice is not a high source of protein compared to the other options. While it does contain some protein, it is primarily a carbohydrate-rich food.

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A nurse is caring for a 2-year-old child who has Clostridium difficile.Which of the following actions should the nurse take?

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A nurse is caring for a 2-year-old child who has Clostridium difficile.
Which of the following actions should the nurse take?