An unlicensed assistive personnel (UAP) applies a pediatric urine collection (PUC) bag on the symphysis pubis of a female infant.
Which action is most important for the practical nurse (PN) to take when checking the placement of the PUC bag?

Choice A rationale

Applying a dry diaper over the PUC bag is a routine step after placement but is not the most important action for checking placement. While necessary for hygiene and containing urine, it does not directly verify the correct anatomical positioning of the collection bag, which is crucial for accurate and contamination-free urine collection in infants.

Choice B rationale

Ensuring the bag's adhesive is secured to the true perineum is the most critical action. Proper placement on the true perineum (the anatomical region between the thighs, encompassing the anus and external genitalia) ensures that urine directly enters the collection bag, preventing contamination from stool or skin flora, and allowing for an accurate and sterile urine sample.

Choice C rationale

Calculating the infant's fluid intake is a separate nursing responsibility related to overall fluid balance and hydration status. It is not directly related to checking the correct placement of a pediatric urine collection bag. While fluid intake influences urine output, it does not provide information about the anatomical accuracy of the bag's application.

Choice D rationale

Asking the mother when the infant previously voided provides historical information about the infant's voiding pattern. While helpful for anticipating when the infant might void again, this information does not confirm the current, proper placement of the urine collection bag. The physical verification of adhesive placement is paramount for effective collection.

Choice A rationale

Obtaining blood gas samples from an umbilical artery catheter (UAC) is a procedure performed by advanced practitioners, such as physicians or specialized critical care nurses, due to the inherent risks of arterial sampling, including vasospasm, thrombosis, and infection. This is beyond the scope of practice for a practical nurse.

Choice B rationale

Administering nebulized inhalation therapy requires a specific prescription and careful assessment of the infant's respiratory status. While PN scope varies, initiating such a therapy without explicit instruction and comprehensive assessment is typically outside a PN's independent practice, especially in a neonate with evolving respiratory needs.

Choice C rationale

Initiating 50% oxygen supplementation is a significant intervention that requires a physician's order and continuous monitoring of the infant's oxygen saturation to prevent hyperoxia, which can lead to complications such as retinopathy of prematurity or pulmonary damage. A PN would not independently initiate this.

Choice D rationale

Assessing and recording oxygen saturation levels using pulse oximetry is a fundamental nursing responsibility and falls well within the scope of practice for a practical nurse. This non-invasive assessment provides crucial data regarding the infant's oxygenation status, guiding further interventions and monitoring the effectiveness of oxygen therapy. Normal range for neonates is typically 90-95% or higher.