Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel on a pediatric unit?

Weigh the diaper of an infant for output.

Assess the dressing of the infant that is two days post-operative.

Calculate the Morse Fall Scale for the preschool child.

Perform assessment of a child's developmental milestones.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Weighing an infant's diaper for output is a task suitable for unlicensed assistive personnel (UAP) because it involves data collection rather than clinical judgment or critical thinking. The results can be recorded and reported to the nurse for further assessment and interpretation.

Choice B rationale

Assessing a post-operative dressing requires clinical judgment to identify signs of infection, dehiscence, or other complications. This task is within the scope of a licensed nurse and should not be delegated to UAP to ensure patient safety.

Choice C rationale

Calculating the Morse Fall Scale involves understanding and interpreting risk factors, which requires critical thinking and clinical judgment. It is inappropriate for delegation to UAP, as they are not trained to analyze or interpret clinical data.

Choice D rationale

Performing an assessment of a child's developmental milestones requires knowledge of growth and development patterns, as well as clinical judgment to interpret findings. This task is outside the scope of UAP and must be performed by a licensed nurse.

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Correct Answer is B

Explanation

Choice A rationale

A positive rubella serum antibody titer indicates immunity to rubella infection, which is protective during pregnancy. It is not an abnormal finding and does not require immediate reporting. Rubella immunity is important to prevent congenital rubella syndrome in the fetus, a severe condition causing defects such as deafness or cardiac anomalies.

Choice B rationale

Blood pressure of 144/94 mmHg is elevated and indicates gestational hypertension, which could progress to preeclampsia if not managed. Preeclampsia can lead to complications such as eclampsia, placental abruption, or maternal and fetal mortality. Normal blood pressure during pregnancy is less than 140/90 mmHg, making this finding critical to report.

Choice C rationale

Copious leukorrhea is a common physiological change in pregnancy due to increased estrogen levels and vascularity. It is usually benign and protective, preventing infections by maintaining a mildly acidic environment in the vagina. This finding does not warrant immediate concern unless associated with infection symptoms.

Choice D rationale

An O-negative blood type requires administration of Rh immunoglobulin to prevent Rh isoimmunization, but this is routinely managed in pregnancy. It is not an urgent issue unless there are concerns about fetomaternal hemorrhage or alloimmunization, which could harm an Rh-positive fetus.

A. Restrict outdoor play activity to 1 hour per day. B. Apply cold compresses when your child expresses pain. C. Offer fluids to your child multiple times every day. D. Monitor your child's temperature daily.

Correct Answer is C

Explanation

Choice A rationale

Restricting play activity limits physical and emotional well-being in children. While strenuous activity is discouraged during recovery, moderate activity promotes overall health and blood flow. Over-restriction is unwarranted without clinical indications. Balance in physical activity should be emphasized in sickle cell management.

Choice B rationale

Cold compresses induce vasoconstriction, which may precipitate a sickle cell crisis by reducing oxygen delivery to tissues. Warm compresses are preferred to improve blood flow and alleviate pain in these patients. Temperature management is critical in preventing vaso-occlusive complications.

Choice C rationale

Adequate hydration reduces blood viscosity, preventing sickling episodes in children with sickle cell anemia. Consistent fluid intake is a cornerstone of management, mitigating crisis frequency. Parents should encourage routine hydration to maintain hemodynamic stability in affected children.

Choice D rationale

Daily temperature monitoring is important but not sufficient standalone advice. Fever in sickle cell anemia may indicate infection or crisis, requiring prompt medical evaluation. However, comprehensive management includes hydration, pain control, and activity regulation alongside temperature monitoring. .

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