A nurse is providing discharge teaching to a client who has a new ostomy.
Which of the following instructions should the nurse include?

"Apply sterile gloves when changing your ostomy pouch.”

"Notify the provider if your stoma becomes pink and moist.”

"Empty your ostomy pouch when it is half full.”

"Use a moisturizing soap to cleanse your stoma.”

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Applying sterile gloves when changing the ostomy pouch is essential for infection control. However, this is a standard practice and not specific to the client's condition. While important, it is not the priority instruction for a client with a new ostomy.

Choice B rationale:

Notifying the provider if the stoma becomes pink and moist is crucial information for the client. A pink and moist stoma indicates good blood supply and healing, while changes in color or moisture might indicate complications. This instruction is essential for the client's ongoing care and to prevent potential complications, making choice B the correct answer.

Choice C rationale:

Emptying the ostomy pouch when it is half full is a general guideline to prevent leakage and maintain hygiene.

Choice D rationale:

Soaps with lotions or perfumes may interfere with the pouch seal or cause peristomal skin irritation. Rinse and dry well.

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Correct Answer is D

Explanation

Choice A reason:

"I try to respond to the baby quickly so she doesn't cry very long." This statement is incorrect because it indicates the parent's sensitivity to the baby's needs and responsiveness to the baby's cues, which are positive signs of appropriate caregiving.

Choice B reason:

"I have several friends who come by to help out with the baby." This statement is incorrect because having a support system in the form of friends who help with the baby is a positive factor that can reduce stress and promote a healthy postpartum period.

Choice C reason:

"I want to meet other parents to see if they are going through the same things." This statement is incorrect because seeking social support and connecting with other parents can be beneficial in reducing feelings of isolation and stress during the postpartum period.

Choice D reason:

"I think the baby should be sleeping through the night by now is the correct statement "I think the baby should be sleeping through the night by now," as a manifestation of increased risk for child abuse. This statement may indicate unrealistic expectations or frustration from the parent regarding the baby's sleep patterns.

It is common for newborns to wake frequently during the night for feeding and care, and their sleep patterns can vary significantly in the early weeks and months of life. Unrealistic expectations or frustration about the baby's sleep habits can contribute to increased stress for the parent, which might increase the risk of child abuse or neglect.

A. Refer the adolescent to a local mental health clinic. B. Advise the adolescent to place the newborn for adoption. C. Contact the adolescent's parent for assistance. D. Assist the adolescent in applying for Medicaid.

Correct Answer is D

Explanation

A. Incorrect. Referring the adolescent to a mental health clinic is not the primary action to address her concerns about affording and caring for her baby.

B. Incorrect. Advising adoption might not be appropriate if the adolescent wants to explore options for keeping and caring for her baby.

C. Incorrect. Contacting the adolescent's parent for assistance may not be feasible or appropriate if the adolescent's situation does not allow for parental involvement.

D. Correct. Assisting the adolescent in applying for Medicaid is a practical step to help her access financial assistance for her pregnancy-related care and the care of her baby.

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A nurse is providing discharge teaching to a client who has a new ostomy. Which of the following instructions should the nurse include?

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A nurse is providing discharge teaching to a client who has a new ostomy.
Which of the following instructions should the nurse include?