The nurse is caring for a 4-month-old infant in the emergency department. The nurse reviews the infant's medical record and assessment findings. Which of the following conditions should the nurse suspect, and what actions should the nurse take to address that condition, and what parameters should the nurse monitor to assess the infant's progress?

The nurse should suspect that the infant has

Choice A reason: This is not a correct instruction for the nurse to include in the teaching. The Pavlik harness is a device that holds the infant's hips in a flexed and abducted position to allow the femoral head to fit into the acetabulum. The harness should not be removed by the parents, as this may interfere with the treatment and cause complications. The nurse should instruct the parents to sponge bathe the infant while wearing the harness.

Choice B reason: This is not a correct instruction for the nurse to include in the teaching. The length of the straps of the Pavlik harness should not be adjusted by the parents, as this may affect the alignment and stability of the infant's hips. The nurse should instruct the parents to bring the infant to the provider's office regularly for check-ups and adjustments of the harness.

Choice C reason: This is not a correct instruction for the nurse to include in the teaching. Massaging the infant's skin under the straps of the Pavlik harness may cause irritation, friction, or pressure on the skin, which may lead to skin breakdown or infection. The nurse should instruct the parents to keep the infant's skin clean and dry, and to check for any signs of redness, swelling, or drainage.

Choice D reason: This is a correct instruction for the nurse to include in the teaching. Placing the diaper under the straps of the Pavlik harness prevents the diaper from interfering with the position and function of the harness. The nurse should instruct the parents to change the diaper frequently and to avoid using bulky or cloth diapers.

Choice A reason: Administering alprazolam 0.5 mg PO is not the first action that the nurse should take. Alprazolam is a benzodiazepine that can be used to treat anxiety or insomnia, but it is not a priority intervention for a mother who has experienced a stillbirth. The nurse should assess the mother's emotional and physical needs before giving any medication.

Choice B reason: Contacting the health care facility's clergy is not the first action that the nurse should take. The nurse should respect the mother's spiritual and cultural beliefs and preferences, but not assume that she wants or needs the clergy's presence. The nurse should ask the mother if she would like to have any spiritual support or counseling.

Choice C reason: Offering the mother private time with the newborn is the first action that the nurse should take. This is a sensitive and compassionate way to acknowledge the mother's loss and grief, and to facilitate bonding and closure. The nurse should provide the mother with a quiet and comfortable environment, and allow her to hold, touch, and talk to the newborn as long as she wishes.

Choice D reason: Assisting the client with transferring to the gynecology unit is not the first action that the nurse should take. The nurse should not rush the mother to leave the labor and delivery unit, as this may increase her sense of isolation and abandonment. The nurse should allow the mother to stay in the same room until she is ready to move, and provide her with emotional and physical support during the transition.