A nurse is reinforcing teaching about colostrum with a new mother who is breastfeeding.
The mother asks, "Why is colostrum so important for my baby?" Which of the following responses should the nurse make?

The correct answer is Choice B.

Choice A rationale: Bradycardia is not typically associated with a perforated appendix. Instead, tachycardia (increased heart rate) may occur due to pain and infection-related systemic responses. Bradycardia could indicate other unrelated medical issues and should still be monitored.

Choice B rationale: Elevated temperature is a key sign of infection and inflammation, which are common with a perforated appendix. The release of bacteria into the abdominal cavity can cause peritonitis, leading to fever as part of the body's immune response.

Choice C rationale: Lethargy can be a nonspecific symptom and may occur in various conditions. While it can be associated with severe infection, it is not a definitive indicator of a perforated appendix. Monitoring for more specific signs, like fever and pain, is crucial.

Choice D rationale: Decreased abdominal girth is unlikely and not indicative of a perforated appendix. Instead, an increase in abdominal girth due to fluid accumulation (ascites) or air (from perforation) would be more concerning and should be reported promptly.

Choice A rationale:

Documenting the medication error in the provider's progress notes is not the appropriate location for documenting a medication error. Progress notes are typically used to record the client's clinical progress and assessments, not incidents of medication errors.

Choice B rationale:

The controlled substance inventory record is used to track the dispensing and administration of controlled substances in a healthcare facility. Documenting a medication error in this record is not appropriate, as it is not the purpose of this document.

Choice C rationale:

Documenting the medication error in an incident report is the correct action. Incident reports are used to document and track adverse events or errors that occur in healthcare settings. This allows for proper investigation, analysis, and the implementation of preventive measures to avoid similar errors in the future.

Choice D rationale:

The nursing care plan is a document that outlines the client's nursing care needs, goals, and interventions. While it may include information about medication administration, it is not the appropriate place to document a medication error. An incident report is specifically designed for this purpose and ensures that the error is appropriately addressed and investigated.