A nurse is providing care to a group of patients with chronic illnesses.

Who among the following patients should the nurse identify as being at the highest risk for sepsis?

Choice A rationale

Vitamin K is not the antidote for heparin. It is used to reverse the effects of warfarin, which is a vitamin K antagonist.

Choice B rationale

Iron is not related to the reversal of heparin. It is a mineral that is crucial for many bodily functions, including the transport of oxygen in the blood.

Choice C rationale

Glucagon is a hormone that raises the level of glucose in the blood. It is not used as an antidote for heparin.

Choice D rationale

Protamine is the correct choice. Protamine sulfate is a drug that reverses the anticoagulant effects of heparin by binding to it and forming a stable complex, thereby neutralizing its anticoagulant activity.

The correct answer is Choice A

Choice A rationale: Ensuring that the mother calls and the nurse takes the baby to the room maintains security and safety protocols. It prevents unauthorized individuals from handling the infant, thus minimizing the risk of abduction or harm.

Choice B rationale: Showing photo identification alone is not sufficient to ensure the safety of the newborn. The nurse should directly handle the transfer of the baby to maintain strict security measures and verify the proper identification in the process.

Choice C rationale: Allowing someone to push the baby in a wheeled bassinet without proper authorization and identification verification does not adhere to safety protocols. The nurse should always verify and manage the transfer to ensure the infant’s security.

Choice D rationale: Carrying the grandchild to the room without adequate identification verification and authorization does not follow safety protocols. The nurse should always be involved in the transfer to prevent any security breaches and ensure the infant’s safety.