A nurse is creating a plan of care for a child who has acute lymphoid leukemia and an absolute neutrophil count of 400/mm³ (2500 to 8000/mm³). Which of the following interventions should the nurse include in the plan?
Encourage friends and family to visit the child.
Provide a low-protein diet for the child.
Collect a daily urine specimen from the child to check for proteinuria.
Withhold administering the varicella vaccine to the child.
The Correct Answer is D
Rationale:
A. Encouraging friends and family to visit the child is not appropriate due to the risk of infections, as the child has a severely compromised immune system.
B. A low-protein diet is not indicated; children with leukemia often require adequate nutrition to support their health.
C. Collecting a daily urine specimen for proteinuria is not specifically indicated for this condition; the focus should be on infection prevention.
D. Withholding the varicella vaccine is essential because live vaccines are contraindicated in immunocompromised patients due to the risk of severe infections.
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Correct Answer is C
Explanation
Rationale:
A. Comparing the nurse's skills to coworkers may not provide an accurate evaluation as it can vary based on individual roles and responsibilities.
B. While client satisfaction reports can reflect overall performance, they may not specifically address time management skills.
C. Maintaining regular notes about the nurse's time management skills allows for ongoing assessment and provides concrete examples during the appraisal, making it the most effective method.
D. Asking another staff nurse for evaluation can introduce bias and may not provide a comprehensive view of the nurse's time management skills.
Correct Answer is D
Explanation
Rationale:
A. Early decelerations are typically benign and often associated with head compression, not necessitating an emergency cesarean birth.
B. A knee-chest position is generally used for variable decelerations but is not indicated for early decelerations.
C. Continuous internal monitoring may be necessary in certain situations, but in the case of early decelerations, it is not an immediate intervention.
D. Early decelerations usually require continued monitoring without immediate intervention as they typically resolve spontaneously with contractions.