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

A.

Weigh the diaper of an infant for output.

B.

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

C.

Calculate the Morse Fall Scale for the preschool child.

D.

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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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

A. Formation of fingers, toes, and facial features

Correct Trimester: 1st Trimester (Conception – 13 weeks)
Explanation:
By the end of the 1st trimester, organogenesis (organ formation) is largely complete.

  • Weeks 7–8: Limb buds appear and begin differentiating into arms and legs.

  • Weeks 9–12: Fingers, toes, facial features (eyes, nose, lips, ears) become clearly defined.
    This is a critical period for congenital malformations if exposed to teratogens.

B. Fetus can hear and respond to external stimuli

Correct Trimester: 2nd Trimester (14–26 weeks)
Explanation:

  • Around 18–20 weeks: The fetus develops the ability to hear sounds.

  • External sounds can startle the fetus, and the heartbeat may change in response.

  • Mother's voice and music can be recognized at this stage.

C. Increase in body fat reserves

Correct Trimester: 3rd Trimester (27–40 weeks)
Explanation:

  • In the final trimester, especially after week 32, fat accumulates under the skin.

  • This provides energy and helps with temperature regulation after birth.

  • The fetus also gains the most weight during this period.

D. Brain develops most rapidly during this time

Correct Trimester: 3rd Trimester (27–40 weeks)
Explanation:

  • Although brain development starts early, the most rapid growth occurs in the third trimester.

  • There's a dramatic increase in brain volume, cortical folding, and neural connectivity.

  • This trimester is essential for cognitive and motor development.

E. Gender can be determined

Correct Trimester: 2nd Trimester (14–26 weeks)
Explanation:

  • By week 18–20, an ultrasound can reliably show external genitalia.

  • The sex organs begin forming in the 1st trimester, but become distinct and visible by the 2nd trimester.

  • This is when many parents find out the baby's gender via an anatomy scan.

Correct Answer is ["6"]

Explanation

The correct answer is Apgar score of 6.

Step 1 is to evaluate each of the five components of the Apgar score at 1 minute:

  • Heart rate: 120/min scores 2 points (normal heart rate is ≥100 beats per minute).
  • Respiratory effort: Slow and weak cry scores 1 point (normal is a strong cry, scoring 2 points).
  • Muscle tone: Some flexion of extremities scores 1 point (normal is active motion, scoring 2 points).
  • Reflex irritability: Grimace in response to suctioning scores 1 point (normal is crying or withdrawal, scoring 2 points).
  • Color: Body pink with blue extremities scores 1 point (normal is completely pink, scoring 2 points).

Step 2 is to sum up the points. (2 + 1 + 1 + 1 + 1) = Apgar score of 6. .

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