A nurse is planning care for a preterm newborn.
Which of the following nursing interventions to promote development should be included in the plan of care?

Choice A rationale

Reporting to a child abuse hotline is a priority intervention when there is a suspicion of non-accidental trauma, such as a spiral fracture in a non-ambulatory infant. Spiral fractures are highly indicative of twisting injuries, which are unlikely to result from a fall and suggest possible abuse.

Choice B rationale

Educating the mother on safety is an important intervention for accidental injuries but does not address the immediate concern of potential abuse. The focus should be on investigating the cause of the injury to ensure the child’s safety.

Choice C rationale

Informing the mother to call the nurse for all diaper changes is not relevant to investigating potential abuse. This action fails to prioritize the safety and protection of the child in cases where abuse is suspected.

Choice D rationale

Completing the Morse Fall Scale assesses fall risk and is not appropriate for investigating the etiology of the injury. It does not address the immediate need to ensure the child’s safety or initiate an investigation into possible abuse.

Choice A rationale

Performing a sterile vaginal exam assesses cervical dilation and effacement, which is essential for labor progression. However, it poses an infection risk after membrane rupture and should follow fetal heart rate evaluation to ensure fetal well-being.

Choice B rationale

Establishing IV access is important for administering fluids or medications. Still, it is not immediately necessary without first assessing the fetal and maternal condition, which dictates further intervention needs.

Choice C rationale

Obtaining the fetal heart rate is the priority after membrane rupture and bloody show. It evaluates fetal oxygenation and well-being, especially with frequent contractions. Tachycardia or decelerations may indicate distress, necessitating immediate intervention.

Choice D rationale

Assessing maternal vital signs provides insight into hemodynamic status but is secondary to immediate fetal monitoring. Fetal heart rate assessment directs urgent management, especially in high-risk scenarios like ruptured membranes and bloody show. .