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 plan. The parents should not remove the harness when bathing the infant, as this may interrupt the treatment and cause complications. The nurse should instruct the parents to sponge bathe the infant while wearing the harness, and to keep the harness clean and dry.

Choice B reason: This is not a correct instruction for the nurse to include in the teaching plan. The parents should not adjust the straps of the Pavlik harness by themselves, as this may affect the position 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 plan. The parents should not place a thin layer of clothing under the straps of the harness, as this may interfere with the proper alignment and function of the harness. The nurse should instruct the parents to dress the infant in loose-fitting clothing over the harness, and to avoid using bulky or cloth diapers.

Choice D reason: This is a correct instruction for the nurse to include in the teaching plan. The parents should check the infant's skin under the straps of the harness for redness or irritation, as this may indicate skin breakdown or infection. The nurse should instruct the parents to keep the infant's skin clean and dry, and to report any signs of redness, swelling, or drainage.

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.