A nurse is assisting with the care of a client who has pneumonia.

For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.

A) "Carry your newborn back to the nursery in your arm when you need to rest.": This statement is not recommended. Carrying the newborn around, especially when the mother is feeling fatigued or unwell, can increase the risk of accidental drops or falls. Newborns should be placed in a bassinet or crib, and if the mother needs to rest, she should use assistance to ensure the baby is safely secured in their sleeping area.

B) "Request that the nurses show their nursing license prior to removing your newborn from the room.": While it’s important to ensure that the staff is authorized to care for the newborn, it may not be practical or necessary to request to see a nursing license every time someone comes to take the baby. Instead, the hospital usually has strict protocols in place for identifying staff, and it is better to rely on the facility's established security measures to verify authorized personnel.

C) "Leave your newborn in the bassinet in your room while you use the bathroom.": This statement is not ideal because, while it may seem safer to leave the baby in the bassinet, the nurse should encourage the mother to keep the baby nearby or alert a nurse to assist if needed. It is safer to have the baby in a secure place or ask for help to avoid the risk of falls or accidents while the mother is not attending to the baby.

D) "Alert the staff if any of your newborn's identification bands are missing.": This is the correct and most important instruction. Newborns should always be closely monitored to prevent abductions or mix-ups, and the identification bands are critical for verifying the baby's identity. If any identification bands are missing, it is essential to notify the staff immediately to ensure the newborn’s safety and prevent any potential security risks.

A) Client report of muscle spasms of the left leg: Muscle spasms are common in clients with a cast, especially if the muscle is restricted for an extended period. While muscle spasms can be uncomfortable, they are not immediately life-threatening. The nurse should still address the discomfort but it does not take priority over other potential issues like circulation.
B) One fingerbreadth of space between the cast and the skin: A small amount of space between the cast and the skin can be normal and is typically observed in a well-applied cast. However, this finding alone does not indicate an immediate concern unless other signs such as swelling or impaired circulation are noted.

C) Diminished pulses on the affected extremity: Diminished pulses are a priority concern. This may indicate compromised circulation, which can lead to serious complications such as tissue ischemia or compartment syndrome. The nurse should immediately assess the severity of the circulation problem, as any signs of compromised blood flow require prompt intervention to prevent permanent damage or loss of limb function.

D) Ecchymosis on the inner left thigh: Ecchymosis or bruising on the inner thigh can be a normal consequence of trauma or injury related to the reason for the cast. While it is important to monitor for any changes in the condition, ecchymosis itself is not immediately life-threatening or urgent compared to potential circulation issues.