An IV site that is red, warm, painful and swollen indicates that phlebitis has developed and the line should be discontinued and restarted at another site. Phlebitis is inflammation of a vein. It is usually associated with acidic or alkaline solutions or solutions that have a high osmolarity. Phlebitis can also occur as a result of vein trauma during insertion, use of an inappropriate I.V. catheter size for the vein, or prolonged use of the same I.V. site.

Option A: Pain on movement should be managed by maneuvers such as splinting the limb with an IV board or gently shifting the position of the catheter before making a decision to remove the line. Apply warm, moist compresses to the area. Document the patient’s condition and interventions.
Option C: An IV line that is running slowly may simply need flushing or repositioning. Monitor administration rates and inspect the I.V. site frequently. Change the infusion site according to the facility’s policy.
Option D: A hematoma at the site is likely a result of minor bleeding at the time of insertion and does not require discontinuation of the line. Avoid veins that are small and/or fragile, veins in areas of flexion, veins in extremities with preexisting edema, or veins in areas with known neurologic impairment.

Fluid overload occurs when the fluid volume infused over a short period is too great for the vascular system, causing fluid leak into the lungs. Symptoms include dyspnea, rapid respirations, and discomfort as in the patient described. Transfusion associated circulatory overload includes any four of the following occurring within 6 h of a BT – acute respiratory distress, tachycardia, increased blood pressure (BP), acute or worsening pulmonary edema and evidence of a positive fluid balance.

Option A: Febrile non-hemolytic reaction results in fever. Febrile non-hemolytic is generally thought to be caused by cytokines released from blood donor leukocytes (white blood cells). Transfusion reactions range in frequency from relatively common (mild allergic and febrile non-hemolytic reactions) to rare (anaphylaxis, acute hemolytic, and sepsis).
Option B: Symptoms of allergic transfusion reaction would include flushing, itching, and a generalized rash. Attributed to hypersensitivity to a foreign protein in the donor product. The severity and incidence vary depending on the type of transfusion reaction, the prevalence of disease in the donor population, and the extent of follow-up care the patient receives.
Option C: Acute hemolytic reaction may occur when a patient receives blood that is incompatible with his blood type. It is the most serious adverse transfusion reaction and can cause shock and death. Can result in intravascular or extravascular hemolysis, depending on the specific etiology (cause). Immune-mediated reactions are often a result of recipient antibodies present to blood donor antigens.

Uterine contractions typically become stronger and occur more closely together following amniotomy. The FHR is assessed immediately after the procedure and followed closely to detect changes that may indicate cord compression. The procedure itself is painless and results in the quick expulsion of amniotic fluid.

Option A: Following amniotomy, cervical checks are minimized because of the risk of infection. Amniotomy is easily performed with the use of specially designed hooks intended to grab and tear the amniotic membrane. The two most commonly used devices are (1) an approximately 10-inch rod with a hook on the end of the rod or (2) a finger cot with a hook on the end of the cot. With either device, the practitioner first assesses cervical dilation through the performance of a sterile digital exam.
Option B: It is commonly felt that relieving the amniotic sac of amniotic fluid induces uterine contraction activity, increases the strength of contractions, and may augment labor by allowing direct pressure from the fetal scalp on the uterine cervix which may assist in dilating the cervix.
Option C: In the case of an unengaged fetal head, rupture of membranes may allow for the umbilical cord to precede the fetal head when the release of amniotic fluid occurs. This will allow the fetal head to compress the section of umbilical cord preceding the head, generally leading to fetal bradycardia and necessitating emergency cesarean section. This complication should be an easily avoidable, iatrogenic cause of emergency delivery.
Option D: The nurse plays a vital role during the procedure in monitoring the mother as well as the fetus, she also notes the color of the draining amniotic fluid and documents the findings in the medical chart. After the procedure, she assesses the maternal temperature every two hours and watches out for any signs of infection. The nurse also monitors the fetal heart rate via continuous electronic fetal monitoring and communicates the findings to the provider.
Option E: Pain is not associated with amniotomy. Practitioners have believed that artificial rupture of membranes either can assist in inducing labor or augmenting spontaneous labor. It is commonly felt that relieving the amniotic sac of amniotic fluid induces uterine contraction activity, increases the strength of contractions, and may augment labor by allowing direct pressure from the fetal scalp on the uterine cervix which may assist in dilating the cervix.

An infant discharged home with hyperbilirubinemia (newborn jaundice) should be placed in a sunny rather than dimly lit area with skin exposed to help process the bilirubin. Phototherapy is started based on risk factors and the serum bilirubin level on the nomogram. Bilirubin absorbs light optimally in the blue-green range (460 to 490 nm) and is either photo isomerized and excreted in the bile or converted into lumirubin and excreted in the urine. During phototherapy, the eyes of the newborn must be covered, and the maximum body surface area exposed to the light.

Option A: Frequent feedings will help to metabolize the bilirubin. Breast milk jaundice occurs late in the first week, peaks in the second, and usually resolves by 12 weeks of age. It is due to inhibition of UGT activity and a factor in breast milk with a beta-glucuronidase-like activity that deconjugates conjugated bilirubin in the intestines leading to increased enterohepatic circulation.
Option B: A recheck of the serum bilirubin and a physical exam within 72 hours will confirm that the level is falling and the infant is thriving and is well hydrated. Bilirubin levels may be assessed using a transcutaneous measurement device or taking blood for total serum or plasma level determination. Transcutaneous measurement decreases the frequency of blood tests for bilirubin but is limited by dark skin tone and if the neonate has received phototherapy.
Option C: Signs of dehydration, including decreased urine output and skin changes, indicate inadequate fluid intake and will worsen hyperbilirubinemia. Breastfeeding jaundice, also known as breastfeeding failure jaundice, occurs in the first week of life and is due to failure of adequate intake of breast milk leading to dehydration and sometimes hypernatremia. Breastfeeding failure leads to decreased intestinal motility and decreases the elimination of bilirubin in the stool or meconium.

All infants under 1 year of age weighing less than 20 lbs. should be placed in a rear-facing infant car seat secured properly in the back seat. Rear-facing car safety seats for infants are perhaps the least controversial; rear-facing car seats have superior effectiveness in preventing serious injury in infants from car crashes. Children < 24 months riding in rear-facing car seats were 1.76 times less likely be seriously injured from all types of car crashes relative to children riding in forward-facing safety seats

Option B: Infant car seats should never be placed in the front passenger seat. States have implemented their own individual mandates for car safety seats, with stringent recommendations from the AAP incorporated into law in New Jersey and Oklahoma and with states including West Virginia (WV) and North Carolina having the most lenient requirements (Bae, Anderson, Silver, & Macinko, 2014; NCPSC, 2013). WV requires that children under 7 years be restrained in a car safety or booster seat, without specifying the timing of the transition.
Option C: The infant should always face rearward in the back seat while on a car seat. For side crashes, children < 24 months riding in forward-facing car seats were 5.5 times more likely to get injured as compared to those riding in rear-facing car seats. Accident data (such as from Sweden) indicate that increased duration of rear-facing car safety seat usage can decrease injuries and deaths relating to automobile accidents (SafetyBeltSafe USA, 2013).
Option D: Infants should always be placed in an approved car seat during travel, even on that first ride home from the hospital. Consistent with research, the American Academy of Pediatrics (AAP) and National Highway Traffic Safety Administration (NHTSA) have developed evidence-based practice guidelines for car safety seat use, which vary by the size and weight of the child, emphasizing the use of rear seats among infants less than 2 years of age (AAP, 2013; NHTSA, 2014).