Which of the following findings requires further action by the nurse? Select all that apply.

A. An assistive personnel weighs and bathes the newborn in an empty client room: While this may not be ideal practice depending on facility policy, it does not necessarily indicate a security threat unless the newborn is removed from secured areas without authorization.

B. Another nurse on the unit requests to take the newborn to the nursery to obtain newborn screening: It is common for nurses to transport newborns for necessary procedures, provided proper identification protocols are followed. This situation does not automatically trigger a security alert.

C. The caregiver and newborn have matching hospital identification bracelets: Matching ID bracelets are part of the standard safety protocol to ensure correct infant identification and prevent abduction. This situation demonstrates proper security measures.

D. A hospital volunteer leaves the unit with the newborn to allow the caregiver to rest: Volunteers are not authorized to transport newborns outside of secured areas. This action represents a serious breach of security and requires the immediate initiation of a security alert to prevent potential abduction or harm.

• Reviewing fetal heart rate tracing: Reviewing the fetal heart rate tracing is the first action because the client has signs of severe preeclampsia, which can quickly lead to fetal distress. The fetal monitor will provide immediate information about the baby’s oxygenation status. Detecting any late decelerations or bradycardia would require urgent intervention to protect fetal life.
• Administering IM betamethasone: Administering IM betamethasone is important to accelerate fetal lung maturity in case early delivery is necessary. Since the client is only at 31 weeks, promoting lung development is crucial to improve neonatal outcomes. However, confirming fetal well-being comes first before giving medications.
• Scheduling an emergency cesarean section: An emergency cesarean section is not the first step without evidence of fetal compromise or maternal instability. At this point, the fetal heart rate shows moderate variability and accelerations, which are reassuring. A cesarean is only scheduled if fetal distress or worsening maternal condition occurs after further monitoring.
• Insert a Foley catheter to monitor urine output: Inserting a Foley catheter is important to monitor kidney function and fluid status in preeclampsia. Reduced urine output can signal worsening disease. However, it is not the priority over assessing the fetal condition first, because fetal distress can occur rapidly and needs immediate identification.
• Administering antibiotics: There is no current indication for administering antibiotics based on the client's data. The client does not have signs of infection, such as fever, elevated WBCs, or positive urinalysis for infection. Administering antibiotics would not address the current primary risks related to severe preeclampsia.