A nurse is caring for a school-age child who is 2 hr postoperative following cardiac catheterization.

The nurse observes blood on the child’s dressing.

Which of the following actions should the nurse take?

This is because the nurse should provide honest and accurate information to the child about the reporting process and the possible outcomes, such as legal actions, investigations, or removal from the home.
This can help the child feel more prepared and less anxious about what will happen next. The nurse should also reassure the child that the abuse is not their fault and that they did the right thing by telling someone.

Choice A is wrong because reassuring the child that no one will be told about the abuse is unethical and illegal.
The nurse has a mandatory duty to report any suspected or confirmed cases of child abuse to the appropriate authorities, such as child protective services or law enforcement. Keeping the abuse a secret can also endanger the child’s safety and well-being, as well as prevent them from receiving the necessary medical and psychological care.

Choice B is wrong because ensuring that multiple nurses are present for the physical examination can increase the child’s fear, embarrassment, or discomfort.
The nurse should minimize the number of people involved in the examination and only include those who are essential for providing care or collecting evidence. The nurse should also explain to the child what will be done during the examination and obtain their consent before proceeding.

Choice D is wrong because using leading statements to obtain information from the child can influence their responses and affect the validity of their testimony.
The nurse should use open-ended questions and avoid suggesting or implying any details about the abuse. The nurse should also document the child’s statements verbatim and avoid interpreting or paraphrasing them.

The correct answer is choice B. Instruct the client to notify the provider if diarrhea develops.

Choice A rationale:

Infusing the medication over 10 minutes is incorrect because penicillin G should typically be infused over 15-30 minutes to ensure proper administration and reduce the risk of adverse reactions.

Choice B rationale:

Instructing the client to notify the provider if diarrhea develops is correct because diarrhea can be a sign of a serious side effect, such as antibiotic-associated colitis, which requires prompt medical attention.

Choice C rationale:

Refrigerating the medication after reconstitution is not necessary for penicillin G. This instruction is more relevant for other medications that require refrigeration to maintain stability.

Choice D rationale:

Checking the client for a sulfa allergy is not relevant to penicillin G, as it is not a sulfa drug. This action would be more appropriate for medications containing sulfonamides.