A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching?

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

Choice A Reason:

Abnormal Involuntary Movement Scale is correct. The Abnormal Involuntary Movement Scale (AIMS) is a standardized tool used to assess and identify tardive dyskinesia, a side effect of antipsychotic medications. Tardive dyskinesia involves involuntary, repetitive movements, typically involving the face, mouth, and sometimes other body parts. Regular monitoring using the AIMS helps healthcare providers detect and evaluate the severity of these abnormal movements, allowing for appropriate management and intervention as needed.

Choice B Reason:

Mental Status Examination (MSE) is incorrect. The MSE is a comprehensive assessment of a person's mental state and cognitive function. While it is valuable for assessing a person's overall mental health and cognitive status, it is not specific for identifying tardive dyskinesia, which is a specific movement disorder.

Choice C Reason:

Brief Psychiatric Rating Scale (BPRS) is incorrect. The BPRS is a tool used to assess the severity of psychiatric symptoms and their changes over time. It is not specific for identifying the physical movements associated with tardive dyskinesia.

Choice D is incorrect:

Patient Health Questionnaire (PHQ) is incorrect. The PHQ is a self-report tool used to screen for symptoms of depression and anxiety. It is not designed for identifying movement disorders like tardive dyskinesia, which are characterized by abnormal physical movements.