A nurse is assisting in the care of clients on a postpartum unit. Which of the following events should the nurse identify as needing to initiate a security alert for?
A hospital volunteer leaves the unit with the newborn to allow caregiver to rest.
Another nurse on the unit requests to take the newborn to the nursery to obtain newborn screening
An assistive personnel weighs and bathes the newborn in an empty client room.
The caregiver and newborn have matching hospital identification bracelets
The Correct Answer is A
A. A hospital volunteer leaves the unit with the newborn to allow caregiver to rest: Hospital volunteers are not authorized to transport newborns, especially off the unit. Removing a newborn without proper clinical authorization represents a significant security risk and requires immediate initiation of a security alert to prevent potential abduction.
B. Another nurse on the unit requests to take the newborn to the nursery to obtain newborn screening: A licensed nurse transporting a newborn for required screening is an expected and appropriate practice. This follows standard hospital protocol and does not indicate a security concern when proper identification procedures are followed.
C. An assistive personnel weighs and bathes the newborn in an empty client room: Assistive personnel may perform routine newborn care under facility policy and nursing delegation. While supervision and proper identification are required, this situation alone does not necessitate a security alert.
D. The caregiver and newborn have matching hospital identification bracelets: Matching identification bands indicate that correct newborn identification procedures are in place. This supports infant safety and does not represent a situation requiring security intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An assistive personnel is encouraging intake of oral fluids: For a client in the active dying phase, forcing or encouraging oral intake can cause discomfort, aspiration, or fluid overload. The focus should be on comfort rather than meeting standard hydration goals, so this requires intervention by the nurse.
B. Supplemental oxygen is in use: Oxygen may be provided for comfort if the client experiences dyspnea. Its use in the active dying phase is appropriate and does not require intervention unless it causes discomfort or is unnecessary.
C. Benzodiazepines are administered every 4 hr: Scheduled benzodiazepines can help manage anxiety, restlessness, or dyspnea in a dying client. This is an appropriate intervention for comfort and does not require nurse intervention.
D. A family member remains at the client's bedside 24 hr each day: Continuous presence of family provides emotional support and comfort for both the client and loved ones. This is consistent with hospice care principles and does not require nurse intervention.
Correct Answer is C
Explanation
A. Rinse the client's skin with hot water: Hot water can damage the skin’s protective barrier, causing irritation and increasing the risk of breakdown. Using lukewarm water is safer and helps maintain skin integrity while cleansing the area.
B. Keep the client’s skin area moist: Excess moisture from urine or feces contributes to maceration and increases the risk of skin breakdown. The skin should be kept clean and dry, not intentionally moist, to prevent irritation and pressure injury.
C. Apply barrier cream to the client's cleansed skin: Barrier creams protect the skin from prolonged exposure to urine and stool, helping to prevent incontinence-associated dermatitis. Applying the cream after cleansing creates a protective layer, maintaining skin integrity and reducing irritation.
D. Apply a thin layer of cornstarch to the client's skin: Cornstarch can clump when in contact with moisture and may promote fungal growth. It is not recommended for protecting skin from incontinence-related irritation and may worsen skin breakdown.
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