A nurse is caring for a group of clients. She plans to delegate obtaining morning vital signs to an assistive personnel (AP) on her team. Which of the following actions should the nurse plan to take?

Rationale:

A. A client who is 4 days postpartum and has mastitis should be assessed, but this condition is less acute compared to the others.

B. A client who had a bilateral tubal ligation 12 hr previously requires post-operative monitoring, but this is less urgent than the client with an ectopic pregnancy.

C. A client admitted 1 hr ago for an ectopic pregnancy is the priority as this condition can be life-threatening and requires immediate assessment.

D. A client who is 1 day postpartum after a late-term miscarriage requires care, but the immediacy is less than that of the ectopic pregnancy client.

Rationale:

A. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate is the most critical task to ensure that the infant is safe and that the postoperative care is being managed correctly.

B. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma is less urgent compared to tasks directly related to patient safety and postoperative care.

C. Collect a stool sample for ova and parasites from a school-age child is important but not as urgent as checking the safety equipment for a postoperative infant.

D. Engage a toddler in play is beneficial but less urgent than tasks related to immediate postoperative care and safety.