The nurse is giving instructions to the mother of a 10-year-old boy who is newly diagnosed with type 1 diabetes mellitus (DM). When attempting to teach the mother how to administer subcutaneous insulin injections to the child, the mother tells the nurse that she is afraid of needles and cannot perform the procedure.
Which intervention should the nurse implement?

Choice A rationale

Gathering supplies for an IV infusion is essential in many cases but not the priority here. Measuring abdominal circumference helps determine if there is abdominal distention indicating a possible blockage, which could suggest a condition like Hirschsprung's disease. Early detection and appropriate intervention are critical, making it the first action.

Choice B rationale

Preparing for anorectal surgery may be necessary if a diagnosis like Hirschsprung’s disease or imperforate anus is confirmed. However, the initial priority is to assess for signs of abdominal distention by measuring the circumference, providing crucial information for the next steps.

Choice D rationale

Monitoring strict urinary output is important for overall fluid balance and identifying complications related to fluid shifts. However, in this scenario, the priority action is to assess for abdominal distention, a potential sign of a serious underlying condition causing the symptoms observed in the infant.

Choice A rationale

The client has a hemoglobin level of 12 g/dL and a hematocrit of 34%, which are within normal ranges for a postpartum woman. A blood transfusion is typically indicated for severe anemia or significant blood loss, neither of which is suggested by these lab results. Therefore, a blood transfusion is not warranted in this case.

Choice B rationale

Rubella vaccination is indicated for a client who is non-immune to rubella, as indicated by the laboratory results. Rubella vaccination is important to protect the client from contracting rubella in future pregnancies, which can cause serious congenital defects. Since the client is not currently pregnant and not immune, vaccination can be safely administered postpartum to prevent future rubella infections.

Choice C rationale

Penicillin G potassium is an antibiotic that might be used for a client who is group B Streptococcus positive to prevent neonatal infection during delivery. However, this client is group B Streptococcus negative, so there is no indication for this antibiotic. There is no need to administer Penicillin G potassium in this scenario.

Choice D rationale

Hepatitis B immunoglobulin is used for newborns of mothers who are hepatitis B surface antigen positive to prevent perinatal transmission of the virus. Since the client's lab results indicate she is hepatitis B surface antigen negative, there is no need for Hepatitis B immunoglobulin. The client and her newborn are not at risk of hepatitis B transmission, so this intervention is not required. .