“A nurse is obtaining a 2-hr postprandial blood glucose from a patient. Which of the following actions should the nurse take?”

Choice A rationale
Decreased extremity edema is a positive sign in a client with deep vein thrombosis (DVT) 48 hours postpartum. DVT is a blood clot that forms in a vein deep in the body, often in the lower leg or thigh. Edema, or swelling, is a common symptom. A decrease in edema may indicate that the condition is improving.
Choice B rationale
Redness in the extremity is not a positive sign in a client with DVT1112. Redness can indicate inflammation or infection, which could suggest a worsening of the condition.
Choice C rationale
Leukocytosis, or an increase in the number of white blood cells, is not a positive sign in a client with DVT1112. It can indicate an infection or inflammation, which could suggest a worsening of the condition.
Choice D rationale
Tachycardia, or a fast heart rate, is not a positive sign in a client with DVT1112. It can indicate a response to decreased oxygen levels in the blood, which could suggest a worsening of the condition.

Choice A rationale
Erythromycin ophthalmic ointment is administered to newborns to prevent neonatal conjunctivitis, also known as ophthalmia neonatorum, specifically for Neisseria gonorrhoeae infection prevention. If the guardian refuses the administration of erythromycin, the healthcare provider should respect the guardian’s decision and document the refusal. It’s important to note that the refusal should be informed, meaning the guardian should understand the potential risks associated with not administering the medication.
Choice B rationale
Informing the guardian that the medication can be given after discharge may not be the best course of action. The purpose of the ointment is to prevent infection immediately after birth when the risk is highest. Delaying the administration could potentially increase the risk of the newborn developing an infection.
Choice C rationale
Reporting the guardian’s refusal of the medication to social services is not the first step unless there are other concerns about the safety or well-being of the child. The healthcare provider should respect the guardian’s autonomy and their right to make informed decisions about the newborn’s care.
Choice D rationale
Notifying the facility’s ethics committee about the guardian’s medication refusal is not typically necessary unless the refusal puts the newborn at significant risk and other attempts to resolve the situation have failed. In this case, the refusal of erythromycin ophthalmic ointment, while not ideal, is not likely to warrant an ethics consultation.