A nurse is caring for a client who has not voided since giving birth vaginally 10 hours ago. Which of the following actions should the nurse take?

Rationale:

• "We should expect the swelling and tingling to worsen before it gets better." This statement needs reinforcement because worsening swelling and tingling can indicate early signs of compartment syndrome. These symptoms are not normal and should prompt immediate medical attention.

• "It is important that our child avoids placing anything inside the cast." This statement reflects understanding because inserting objects inside the cast can break the skin and introduce bacteria, leading to infection. It may also damage the padding and compromise skin protection.
• "We should prop the casted arm on pillows for the next 24 hours." Elevating the limb helps reduce swelling and pain by improving venous return. Keeping the casted arm elevated is a standard part of cast care teaching after an injury.
• "We should notify the provider if the cast becomes loose over time." A loose cast may no longer immobilize the fracture effectively and can allow excessive movement. It may also rub the skin, increasing the risk of irritation or breakdown.
• "We need to be very careful about how we handle the cast for the first 2 days while it dries." This shows understanding because a plaster cast takes 24 to 48 hours to fully dry. Improper handling can cause pressure indentations, leading to skin damage and poor cast integrity.

Rationale:

A. Administer the medication as prescribed: Administering amoxicillin to a client with a penicillin allergy can result in serious allergic reactions, including rash, hives, or anaphylaxis. Amoxicillin is a penicillin derivative, it is contraindicated in patients with penicillin allergies.

B. Discuss the prescription with the health care provider: The nurse must clarify potentially harmful prescriptions directly with the provider. This ensures patient safety by verifying if the medication should be changed, considering the client’s documented allergy to penicillin.

C. Call the pharmacist for clarification of the medication contraindications: While pharmacists can verify drug classes and potential reactions, they do not have the authority to discontinue or modify a prescription. Only the healthcare provider can make necessary changes to an order.

D. Place an incident report in the medical record: Incident reports are meant for internal documentation and are never placed in the client’s medical record. Since the error has not occurred yet, prevention through provider consultation is the priority action.