A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following actions should the nurse take?

A. Provide discharge instructions: Delivering discharge teaching requires nursing judgment, individualized education, and assessment of the client’s understanding. This task cannot be delegated to assistive personnel because it involves critical thinking and evaluation to ensure safe and effective patient self-care.

B. Perform chest compressions during cardiac resuscitation: Performing chest compressions is a technical skill that does not require nursing judgment and can be safely delegated to assistive personnel. During a code, APs can provide life-saving support under the direction of the RN or code team, making this task appropriate for delegation.

C. Perform a dressing change for a new amputee: Changing a surgical dressing, particularly for a new amputation, requires assessment of the wound, monitoring for signs of infection, and clinical judgment regarding complications. This task should remain the responsibility of the RN and is not suitable for delegation to an AP.

D. Assess effectiveness of antiemetic medication: Evaluating medication effectiveness involves clinical assessment and interpretation of patient response. This requires professional nursing judgment and cannot be delegated, as the RN must decide if additional interventions or medications are necessary.

A. Schedule routine oral suctioning: Suctioning can increase intracranial pressure and should be performed only when necessary, using short, gentle passes. Routine suctioning is not recommended for a child with increased ICP, as it can exacerbate neurological injury.

B. Pad the side rails of the bed: An unresponsive child is at high risk for injury from involuntary movements or seizures. Padding the side rails helps prevent trauma and is a key safety intervention in children with increased intracranial pressure, making it the priority action in this scenario.

C. Obtain isolation supplies: Isolation precautions are only needed if the child has a contagious condition. Increased intracranial pressure does not automatically indicate a risk of infection transmission, so isolation supplies are not immediately necessary.

D. Place the child in Trendelenburg position: Trendelenburg positioning (head-down) can further increase intracranial pressure and is contraindicated. Children with elevated ICP should be positioned with the head of the bed elevated to promote venous drainage and reduce pressure.