A nurse is conducting an admission assessment on a newborn. Which of the following findings should the nurse identify as an indication of sepsis?

A. Document the client's level of understanding about potential adverse effects: Documentation is important but should occur after assessing the client’s knowledge and providing teaching.

B. Determine the client's knowledge about diaphragm use: Assessment is the first step in the nursing process. Understanding the client’s baseline knowledge allows the nurse to tailor teaching and identify misconceptions before providing instruction.

C. Supervise return demonstration of diaphragm use: Return demonstration evaluates learning but is only appropriate after teaching and assessment have been completed.

D. Teach the client how to insert the diaphragm: Teaching is essential but should follow assessment of the client’s current understanding to ensure the instruction is effective and appropriate.

Rationale:

A. Check the cords of the IV pump for fraying: Inspecting electrical cords for fraying or damage is an important safety step before use. Damaged cords can cause electrical shock, fire hazards, or equipment malfunction, so this helps ensure safe operation.

B. Remove the safety inspection sticker before plugging in the IV pump: Safety inspection stickers indicate that the device has passed electrical and functional safety checks. Removing them would eliminate visible proof of inspection and is not necessary for safe use.

C. Ensure that the electric outlet has two prongs for the IV pump: Medical equipment such as IV pumps should be plugged into grounded three-prong outlets to reduce the risk of electrical shock. Two-prong outlets do not provide this grounding protection.

D. Grasp the IV pump cord when unplugging it from the electrical outlet: Pulling on the cord can damage the internal wires and increase the risk of electrical hazards. The correct method is to grasp the plug itself when disconnecting from the outlet.