A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?

Choice A Reason:

Determining the client's level of consciousness is correct. Delirium is characterized by a sudden change in mental status, including altered consciousness, confusion, and impaired attention. Assessing the client's level of consciousness helps the nurse understand the severity of the condition and whether the client is experiencing any immediate risks.

Choice B Reason:

Administer an anxiolytic medication is incorrect. Medication administration should not be the first action because the nurse needs to assess the client's condition first to determine if medication is appropriate. Additionally, the underlying cause of the delirium should be identified and treated if possible.

Choice C Reason:

Keep lights on in the client's room is incorrect. While maintaining proper lighting can be important for safety, it is not the first action because it doesn't address the underlying cause or assess the client's level of consciousness.

Choice D Reason:

Encouraging visits from family members is incorrect. Involving family members can provide emotional support, but it's not the first action because the client's condition should be assessed and stabilized before involving others in care.

The guideline of being able to fit one finger between the mattress and the side of the crib ensures that there is a safe space to prevent entrapment and suffocation risks.

Placing a newborn on a pillow for sleep is unsafe. Infants should be placed on their backs to sleep on a firm, flat surface without pillows, blankets, or soft bedding. This reduces the risk of suffocation or sudden infant death syndrome (SIDS).

Attaching a pacifier to the newborn's clothing with a string is hazardous. Strings and cords pose a strangulation risk. Pacifiers should be used according to safe guidelines, but they should not be attached to the baby's clothing with any type of string or cord.

Placing a newborn's crib near a heat vent can result in overheating, which is a safety concern. It is important to keep the baby's sleep environment at a comfortable temperature without direct exposure to heat sources or drafts