The nurse is caring for a child with osteomyelitis.
Which of the following interventions is a priority?

Choice A rationale

Allowing a teenager with suicide ideation to keep personal belongings, especially sharp objects, presents an immediate and significant safety risk. Such items can be readily used for self-harm, undermining the primary goal of ensuring the patient's physical safety in a hospital environment. The environment must be strictly controlled to remove potential means of self-injury.

Choice B rationale

While continuous monitoring is crucial for a teenager with suicide ideation, checking on them every hour is insufficient. The inherent risk of self-harm requires constant, direct observation to intervene immediately if the teenager attempts to harm themselves. Hourly checks leave ample time for potential self-injurious behaviors to occur unsupervised.

Choice C rationale

A no-suicide contract, while sometimes used as a therapeutic tool, does not guarantee that a teenager will not harm themselves. It relies on the patient's commitment, which can be overridden by intense emotional distress or impulsive urges. This intervention should never replace stringent safety measures like continuous supervision and environmental control in an acute setting.

Choice D rationale

Removing any items that could be used for self-harm and providing continuous supervision are essential safety interventions. This creates a secure environment by eliminating immediate means of injury and ensures constant observation, allowing for immediate intervention during an emergent situation. This approach directly mitigates the risk of self-harm in a vulnerable patient.

Choice A rationale

Contractions that increase in intensity are a hallmark of true labor. In true labor, uterine contractions become stronger, more regular, and longer in duration due to increasing myometrial activity and prostaglandin release, which contribute to cervical effacement and dilation. This differs from Braxton Hicks contractions, which typically remain mild.

Choice B rationale

Leakage of fluid from the vagina, often referred to as rupture of membranes, signifies the spontaneous breaking of the amniotic sac. This event can occur before or during true labor and increases the risk of infection and cord prolapse. It is a definitive sign that the labor process has begun or is imminent.

Choice C rationale

Increased bladder pressure is a common discomfort experienced by pregnant clients due to the growing uterus compressing the bladder. However, it is not a specific indicator of true labor. It can occur throughout the third trimester as the fetal head descends into the pelvis, regardless of labor onset.

Choice D rationale

Blood-tinged vaginal mucus, also known as "bloody show," results from the softening and effacement of the cervix, causing capillaries to rupture and release a small amount of blood mixed with mucus. This is a common sign indicating that the cervix is undergoing changes in preparation for labor.

Choice E rationale

Uterine contractions that decrease with rest are characteristic of Braxton Hicks contractions, or "false labor.”. True labor contractions, in contrast, persist and often intensify with activity and do not diminish with rest or changes in position, reflecting progressive physiological changes of labor.