A school counselor refers a teen for evaluation after she gives away personal belongings and writes about death in her journal.
What is the nurse's priority action?

Choice A rationale

Notifying the healthcare provider immediately and requesting antibiotics is premature. Slight redness around pin sites without drainage or pain, and stable vital signs, does not immediately indicate a significant infection requiring systemic antibiotics. This initial finding warrants a thorough assessment and local care before escalating to medical intervention.

Choice B rationale

Removing crusting around pin sites can be detrimental. Crusting can serve as a protective barrier. Aggressive removal can introduce bacteria into the pin tract, increasing the risk of infection, or cause unnecessary pain and trauma to the delicate healing tissue. Gentle cleansing is preferred over forceful removal of adherent crusts.

Choice C rationale

Cleansing the pin sites using sterile saline and assessing for signs of infection is the best immediate action. Slight redness without drainage is often a normal inflammatory response to the foreign body and movement. Sterile saline effectively cleanses without irritating the tissue, and continued assessment helps monitor for evolving signs like increased redness, purulent drainage, or fever.

Choice D rationale

Documenting findings as normal and continuing routine assessments is insufficient. While slight redness can be normal, it still requires diligent monitoring and appropriate pin site care to prevent potential complications. Assuming normalcy without active intervention like cleansing could allow a minor irritation to progress to a more serious infection. .

Choice A rationale

Support during labor has been shown to significantly decrease the perception of pain. Continuous presence of a supportive individual, such as a doula or partner, provides comfort, encouragement, and various coping mechanisms, which can physiologically reduce stress hormone release and enhance the body's natural pain-modulating systems, leading to a less painful experience.

Choice B rationale

A supportive presence during labor contributes to an improved overall experience for the client. The emotional, physical, and informational support provided can alleviate anxiety, empower the client, and foster a sense of control and confidence, leading to a more positive and satisfying childbirth experience, often with lasting beneficial psychological impacts.

Choice C rationale

Support during labor can contribute to better fetal outcomes by reducing maternal stress and anxiety. Lower maternal stress levels can lead to improved uterine blood flow and oxygenation to the fetus. Additionally, continuous support can lead to fewer interventions, such as operative deliveries, which are associated with potential risks to the fetus.

Choice D rationale

Research indicates that continuous support during labor is associated with improved client outcomes. This includes a reduced likelihood of medical interventions, such as epidural anesthesia, synthetic oxytocin for augmentation, and cesarean sections. Enhanced emotional well-being and reduced maternal stress hormones also contribute to a more positive physiological response during labor.

Choice E rationale

Support during labor is known to decrease, not increase, anxiety. The presence of a supportive individual provides reassurance, reduces fear of the unknown, and offers comfort. This contributes to a calm environment, which can physiologically mitigate the stress response, thereby lowering anxiety levels and promoting a more relaxed labor progression for the client.